As an art psychotherapist, I am often asked how working with art can facilitate recovery from sexual abuse. This sometimes difficult to explain in words alone and the confidentiality of the work made in art therapy prohibits the sharing of visual material. In a brave exception to this rule, a client of mine, Maxine*, has given me full permission to share her story. I am indebted to her for allowing me to use her work to demonstrate how art psychotherapy can help children and adults heal from the trauma of sexual abuse.

*All names have been changed to preserve anonymity

Sexual abuse and art therapy: a case study

Post-traumatic stress disorder is a response to experiencing or witnessing an overwhelming traumatic event, or series of events and has been acknowledged as one of the long-term effects of child sexual abuse (Briggs & Joyce, 1997). Maxine was 16 when I began working with her and had a PTSD diagnosis. She had experienced a decade of sexual abuse by her grandfather and violent a rape at gunpoint by a stranger when she was 8. She was disturbed by flashbacks and nightmares of the abuse, to the point where she was afraid to sleep.

Connecting with the body

In one of her early sessions, I asked Maxine to visually represent how she felt emotionally on a daily basis. Her artwork allowed me to see a visceral picture of her trauma that would have been difficult to achieve verbally. The scared and nervous feelings around the legs and stomach signify the triggering of the nervous system, what are called the ‘hyper arousal’ symptoms of PTSD: panic, anxiety and being easily scared or startled.

Dissociation

In ‘The Black Hole’ Maxine expressed a feeling of dissociation. This is a post-traumatic symptom, which is occurs when a person ‘zones out’ during a traumatic event in order to cope. It is linked to the evolutionary freeze response (Gantt & Tinnin, 2008). The trauma therapist Babette Rothschild describes dissociation as ‘an instinctive response to save the self from suffering’ (2000:13). 

At the time of the abuse dissociation is an adaptive strategy, which allows the survivor to develop a self that is abused and a self that can collude with the abuser for survival. When the survivor is no longer exposed to the abusive situation this strategy becomes maladaptive and can keep them socially and emotionally isolated, as they dissociate in everyday life. In ‘The Black Hole’ the use of the art media showed me how distant and separate Maxine felt from those around her.

Reflecting on this painting at the end of therapy, she said that the large spike bursting her through the bubble may have reflected her wish to be awoken from the dissociative state. The lack of arms of the people in the image convey a sense of powerlessness and inertia.

Splitting

Splitting of the self is another dissociative symptom of PTSD, which trauma therapist Judith Herman refers to as the ‘abused and exalted self’ (1992: 106). Art psychotherapy’s unique advantage is that the art object can contain the duality of the ‘dissociative fragments’ (van der Kolk, 1987: 184) of a traumatized client. The good and bad self (Klein, 1946) can be expressed simultaneously in an artwork, whereas the bad self can often become split off if addressed only verbally.

‘In bed’ shows a clear demonstration of this phenomenon in Maxine’s process. The bad self appears small and helpless below the rain cloud and a mere shadow lying next to the good self. In the sunshine, the good self appears strong, more adult in stature and holding a dog that Maxine often cited as her only protector. This piece marked a moment in her therapy where Maxine’s daytime PTSD flashbacks began to abate as she realized that she was now not as helpless as she had been at the time of the abuse. The defiant figure on the left or ‘good self’ seems to acknowledge this.

The sense of touch and the brain

Working physically with art materials can have a positive effect on the hyper-arousal symptoms of PTSD. In child trauma survivors, it was found that by becoming aware of different parts of the body moving during the manipulation of art materials (known as kinesthetic activity), released tension, facilitated relaxation and increased ability to tolerate stress (Chapman et al, 2001). A British survey of sexually abused young people found that the creative art process reawakened physical sensations that they had blocked out (Murphy, 1998). 

The use of clay, with its need to be manipulated with the hands can connect survivors to the haptic sense (the sense of touch). The sensations from joints and muscles experienced in the manipulation of art materials activate emotions because the amygdala (where we process emotions) connects directly to the primary somatosensory cortex (where we process bodily sensations) and to the occipital lobe (where we process visual information) creating a neurobiological link between touch, visual perception and emotion (Lusebrink, 2004:127).

At the beginning of my therapeutic relationship with Maxine she produced ‘A flower’, a phallic symbol made of clay. Hagood (2000) speaks of the re-enactment of sexual abuse that can be stimulated by fluid materials, referencing bodily fluids. The coil pot that surrounds the flower had been made jointly and after its completion Maxine decided to create the flower part which she told me she ‘wanted to stand up’. Being able to use the symbol of the flower to represent a penis permitted Maxine to bring her traumatic experience to the therapy room via the art. At the end of her therapy, Maxine reflected that had I interpreted the symbol of the flower at that point in her therapy, she may not have continued, as it would have been too overwhelming for her. The use of symbolization in the artwork enabled her to process the trauma and bring her experience to the therapy room at a tolerable pace without flooding her with traumatic memory and retraumatizing her.

Narrative building with art

As trauma memories are so fragmented, there is natural tendency for clients to want to map out their trauma in some way to make sense of it, connecting visual fragments with language. Halfway through a year of working with Maxine, she spontaneously produced ‘The Charm Bracelet’. This was a trauma narrative that charted her abuse throughout her life, the sinister metaphor of the charm bracelet as her life and the incidents of abuse as ‘charms’ given to her by her abusers, added on every year.

This piece of work seemed to have a dual purpose, it put Maxine’s abuse history and our work together into a context, but it also appeared to lessen her difficulty in naming and feeling emotional states. The work described the abuse in great detail, but it was this conscious rendering of PTSD triggers and a timeline of events that contextualized her experience. 

It was a unification of explicit memory (cognitive, conscious, and language-based) with implicit memory (emotional, visual and sensory).  As the area of the brain responsible for language shuts down during traumatic experience (Rausch et al, 1996) traumatic memories are recorded visually. Therefore, connecting both body-based memory, image and language allows the trauma to processed and converted into autobiographical memory, which no longer triggers the amygdala (where fear is processed in the brain). This marked a decrease in Maxine’s PTSD hyperarousal symptoms.

Expression of rage and finding resolution

The angry feelings towards the perpetrator can be physically enacted with the art materials, which can help to prevent the child from turning the anger inwards or enacting it in the form of self-harm (Ambridge 2008; Murphy, 1998). The expression of rage by the sexually abused child is facilitated by the kinesthetic aspects of working with the art materials. The expression of anger can lessen depressive symptoms and can be worked towards as a therapeutic goal. If the abuse was perpetrated by a family member, anger often had to be repressed in order for the child to survive. 

The expression of anger can be adaptive for a period of time, but if it becomes stuck or frozen in repetitive re-enactment it can retraumatize the survivor (Herman, 1992; Gil, 2006). After a long period of establishing the trauma narrative of Maxine’s abuse, she announced that she would like to make a model of her rapist.

The act of stabbing the rapist with sticks in his mouth and body seemed to replicate the oral sex acts Maxine had been forced to perform and the painful intrusion in her physically immature body that penetration had caused her. She described it as a ‘sacrifice’ and the process had a ritualistic feel. After the artwork was completed she acknowledged that she would never be able to ‘get even’ with her abuser, but the symbolized revenge marked a change in her behaviour, where she turned her anger into the ‘righteous indignation’ (Herman, 1992: 189) that began to allow her to accept her experience. At the end of her therapy, she smashed it up and this appeared to provide great catharsis.

References

• Ambridge, M. (2008) The anger of abused children. In: Liebmann, M. (ed.). Art Therapy and Anger. London: Jessica Kingsley Publishers. pp.27-41.

• Briggs, L. & Joyce, P.R. (1997) What determines post-traumatic stress disorder symptomatology for survivors of childhood sexual abuse? Child Abuse & Neglect. 21(6) pp.575-582.

• Chapman, L., Morabito, D., Ladakakos, C., Schreier, H. & Knudson, M.M. (2001) The effectiveness of art therapy interventions in reducing post traumatic stress disorder (PTSD) symptoms in pediatric trauma patients. Art Therapy. 18(2) pp.100-104.

• Gantt, L. & Tinnin, L.W. (2008) Support for a neurobiological view of trauma with implications for art therapy. The Arts in Psychotherapy. 36(3) pp.148-153.

• Gil, E. (2006) Helping Abused and Traumatized Children: Integrating Directive and Nondirective Approaches. New York: Guilford Press.

• Hagood, M.M. (2000) The use of Art in Counselling Child and Adult Survivors of Sexual Abuse. London: Jessica Kingsley Publishers.

• Herman, J.L. (1992) Trauma and Recovery: From Domestic Abuse to Political Terror. New York: Basic Books.

• Klein, M. (1946). ‘Notes on some schizoid mechanisms’, International Journal of Psychoanalysis, 27 pp.99-110.

• Lusebrink, V.B. (2004) Art therapy and the brain: An attempt to understand the underlying processes of art expression in therapy. Art Therapy. 21(3) pp.125-135.

• Murphy, J. (1998) Art therapy with sexually abused children and young people. International Journal of Art Therapy: Inscape. 3(1) pp.10-16.

• Rausch, S.L., van der Kolk, B. A., Fisler, R.E. & Alpert, N.M. (1996) A symptom provocation study of posttraumatic stress disorder using positron emission tomography and script-driven imagery. Archives of General Psychiatry. 53(5) pp.380-387.

• Rothschild, B. (2000) The Body Remembers: The Psychophysiology of Trauma and Trauma Treatment. New York: Norton.

• van der Kolk, B.A. (1987) Psychological Trauma. Washington, DC: American Psychiatric Press.