To Investigate The Role Of Art Therapy

Introduction

In the developmental psychology, human relationship is the fundamental key of physical and psychological well-being, as human survives by depending on each other. According to the first and second principle of sociocultural level of analysis, human relationship is built because human being has the basic needs which are to belong and to adapt with the surroundings. The variety of relationships are ranging from friendship, mother-child, siblings and couples with love as a strong basic. Especially during the adolescence year (13-19 years old), romantic relationship love that is shared with compatible partner gives a meaningful experience for them. Love is an innate necessity, similar to the instinctive fear of rejection and disapproval of others. Despite the paramount role they act in our lives, maintaining healthy relationship with romantic partner is difficult.

According to the Triangular Theory of Love by Robert J. Sternberg (1997), love can be explained upon three components; intimacy, passion and commitment which portray different aspect of love. Intimacy is the feeling of closeness and warmth shared between a loving couple. Passion is the physical attraction, sexual desires and romance shared in a loving relationship. Commitment is the quality of dedicating themselves for loving each other through direct or indirect promises of maintaining the love and relationship a couple had. Three combination of the components is called as consummate love. Consummate love would generate a long lasting love relationship which is mostly experienced in the adulthood. Moreover, romantic love which is the combination of intimacy and passion is the basic stage of adolescence love that primarily involved communication, emotion, empathy, identity and sex for some individualist cultured couples.

Nevertheless, according to The Passionate Love Scale developed by Susan Sprecher et al (1986), there is a passionate love that appears in a complex relationship. Passionate love is an emotionally and physically draining relationship, due to the high expectation sustained in the relationship. Emotional and physical satisfactory is the principle of the relationship, which both parties must physically attached to each other as a form of trust and companion. It concludes that couples who uphold intimacy and passion components establish high expectation, they are easily feel dissatisfied by their unfulfilled expectations from the partner. The disappointment may lead to physical abuse, performed by the dominant partner. Physical abuse in adolescent romantic relationship is classified under Teen Dating Violence (TDV). Teen dating violence is physical, sexual, emotional and verbal violence performed within adolescence romantic relationship.

However, physical abuse has been one of the most frequent type of violence within adolescence. Teen dating violence is caused by both internal and external factors, in concern towards the victim’s passivity and lack of self-defense in encountering the abusive behaviours performed by the dominant partner. The inability to defend is caused by these following internal factors; physical disabilities, low-self esteem, unstable mental and emotional well-being. Meanwhile, the external factor is predominantly caused by media. The cultivan theory carried out by Gerbner et al (1994), claim that media violence construct children’s perception towards the world as a barbaric environment. The immediate comprehension of violence as a key of conflict resolution is cognitively implanted.

The recognition of violence as an acceptable behaviour remain until the adolescence and adulthood to some extent. Furthermore, early attachment with the caregiver is the result of external and internal factors which can determine how we behave in the future relationship with dating partner (Hazan and Shaver, 1987). It shapes our personality and set our expectation of how the partner should behave. Insecure attachment and unfulfilled expectations may lead to teen dating violence, specifically physical abuse (Bonache H. et al, 2017). Adolescence, both perpetrators and victims, tend to express their anger through physical actions, due to their high level of aggression in the current age and have lack of self-defense due to the insecure attachment. Perpetrators and victims may experience psychological issues in the near future, however, the victims endure more suppression (Nicole M. L. Buck et al, 2012). Physical abuse victims with low resilience are more prone to experience PTSD once they are exposed to violence with the symptoms of trauma, depression and social problems.

Art therapy is one of the ways to reduce the impact of PTSD which involves the psychoanalysis theory by Sigmund Freud with the projective test as one of the methodology. Freud believe that people can be healed through therapy that gives them insight or motivation in dealing with the problems. In projective tests the patient communicate information from their unconscious mind through the drawing tests.

Afterwards, the therapist analyze and interpret the artworks to assess the strengths and weakness of the patients, therefore, therapist can help them to manage depression, handle trauma and help to accept the situation without feeling burdened again. The progress is monitored by the ‘expected outcome list’ created by the therapist for each of the patients. Art therapy involves creative process through the usage of art media as a communication tool, which aimed to improve an individual’s physical, mental and emotional well-being, cognitive function, and commonly used to treat mental illness including PTSD as a result of teen dating violence. Furthermore, the scope of this research will be done under the research question: To what extent can art therapy treat PTSD due to physical abuse in adolescence romantic relationship?

Human Relationship

Adolescence: “Intimacy and Passion” Furman and Wehner (1994) establish a behavioral system model to understand the various developmental tasks accomplished by adolescent romance. Adolescent behavioral system model is constructed upon four systems; affiliative, which indicate companionship, reciprocity and cooperation; sexual/reproductive, which indicate physical intimacy and the potential for procreation; attachment, which indicate love, closeness, bonding, and feelings of security; and caregiving, which indicate support and assistance between partners. Affiliative and sexual/reproductive phases has high level of occurrence in adolescent romantic relationship, right before it develops into attachment and caregiving systems.

However affiliative and sexual/reproductive phases may not lasts until early adulthood. Furman and Wehner combined Hazen and Shaver’s (1987) attachment theory, and Sullivan’s (1953) social needs theory in key relationships from infancy through adolescence. Each systems, are correlated to each other, which means when the attachment is active the sexual and affiliative systems are also active. Brown (1999) and Connolly and Goldberg (1999) establish the phase- or stage-based models of progression of romantic experience during adolescence. Progression models is constructed upon four phases and the key feelings; initiation, indicate limited contact between potential partner is limited, yet the key feelings are built upon attraction and desire; affiliation indicate the contact between potential partner is built in the affiliation phase, as adolescents learn to interact with the opposite sex in group settings; intimate, indicate partners begin to focus on the emotional attachment and dyadic relationship, by distancing themselves from the group; and committed, which indicates the attachment between the couple arose along with the shared physical and emotional intimacy, and caring behaviour.

These models have similar hypothesis, which suggest that the normative adolescent relationship experience would start in early adolescence with a short-lived relationship that is characterized by group dating. In middle adolescence, the couple will build a relationship that focuses on sexual and emotional intimacy. In late adolescence or early adulthood, committed, sexual and longer duration of relationship will be established (Seiffge-Krenke 2003). There are two types of adolescence relationship, which is classified as; steady and casual, which may differ by gender. More females are reported to be in a steady relationship, and more males are reported to be in a casual or no relationship status. Females are known as their capability in maintaining a relationship longer, compared to male. Older adolescents demand more support from their partners compared to younger adolescents who feel more motivated by their family and friends (Seiffge-Krenke 2003). Females are more focused in relationships than males. Boys think that their partner (girls) have greater power in influencing and driving the relationship.

Environmental and biological factors on romantic relationships in adolescence A prospective study conducted by Connolly and colleagues (2004), investigated whether adolescence pass through each phases of romantic relationship models, and whether in a year, adolescents have the tendency to stay on one phase or move forward to another phase. They used convenient sampling on Canadian 5th through 8th graders. They discovered that adolescents tend to progress rather than regress, by going through the stages sequentially over a year of expanse. However, the progress varies in term of divergent cultural background. Cultural background determine when and how dating begins. Western people started dating in the early adolescence and have more dating and sexual partners, compared to Asian who started dating later preferably at middle adolescence, with lesser dating partners and exclusion of sexual interaction.

In the early adolescence, teenagers tend to consider recreation and achieving peer status as the reason for dating, which differ from the late adolescent's intention of dating. By late adolescence, teenagers seek for someone who can comfort them with intimacy, affection, companionship, and social support (Furman, 2002; Shulman & Kipnis, 2001).

Teen Dating Violence

Physical abuse in adolescent romantic relationship is also known as teen dating violence (TDV), which refer to a lethal violent act that is performed in the relationship. TDV may implicate into severe short and long-term physical and mental issues. Both male and female adolescence are recorded as perpetrator.

However, male adolescent tend to perpetuate physical violence towards their female dating partner, which profound psychological consequences. Despite each individuals have different experience in both context of perpetration and victimization.

A study published in 2007, investigated the causation of TDV and mental health outcomes of 671 male and 720 female late adolescents from 31 public middle and high schools in Minneapolis and Saint Paul, Minnesota. The researchers collected the data by longitudinally with 5 years of gap, and measured TDV exposure and several mental health indicators. The result showed that women who were exposed to TDV experienced higher rates of depression, body dissatisfaction and low self-esteem, compared to male victims.

Cause and Effect Adolescence developmental stage indicate the maturity of the way people handle relationship problems. Unfinished development of prefrontal cortex, unstabilize adolescent’s anger as their logical thinking is still fairly patchy. Therefore, once a conflict emerged, the superior ones are authorized to suppress the inferior ones, since the victim is incapable of resolving conflicts through verbal and physical defense. A prior psychological disruption must be experienced by the victim, which provides the root of the problem and trigger further psychological symptoms, such as lack of low self-esteem and low resilience. Insecure early attachment, has equip the victim to become a mentally and physically insecure individual (Ainsworth, 1987).

As the consequences, avoidant children feel unloved, insecure and rejected and they are more likely to be the victims. Avoidant children experience low self-esteem, which diminish their power to defend themselves. They think themselves unworthy and unacceptable, due to the rejecting the caregiver (Larose, & Bernier, 2001). Meanwhile, ambivalent children build a negative self-image, and seek for attention by exaggerating their emotional response towards normal and serious situation (Kobak et al. , 1993). Early attachment with the primary caregiver determine our interaction in the future dating relationship. Hazan and Shaver (1987), observed the continuity in attachment patterns in romantic love. Hazan and Shaver proposed a pattern of relationship that may remain throughout the lifespan which is called as the continuity hypothesis. Hazan and Shaver studied whether the adolescence relationship with their dating partner shows the same attachment pattern as relationship between children and parent in the early childhood. Various experiences attachment histories influence future romantic love attachment (Hazan and Shaver, 1987). Avoidant type tends to hide their emotions from showing through their actions.

Thus, a facade security and composure appear, and continue to leave suppressed distress unresolved since they do not have the capability to ineluctable hindrances. PTSDTDV may lead to both short and long term consequences that involves psychological and physiological changes. Short term impacts include; depression, anxiety suicidal ideation, alcohol abuse, cigarette and drug use. Long term impacts linked to low self-esteem, disordered eating behaviours, poor mental measures, and post-traumatic stress disorder. Relationship violence that was built in adolescence will continue to thrive into adulthood (Hazan & Shaver 1987). Symptoms begin within three months or a year after the traumatic incident. There are four symptoms of PTSD.

At first, there is a tendency to relive the event then the emergence of flashback involves five senses; sight, hearing, taste, smell and touch, that recall the traumatic events. PTSD victims body exaggeratedly trembles and sweats uncontrollably with seizures of anxiety. The realistic and scary situation may also relieved through nightmares. Second symptom is avoiding things that remind you of the event. PTSD patients tend to avoid certain situation or people that trigger the traumatic event and tend to make themselves busy with other things. Third symptom is having more negative thoughts and feelings than before. PTSD patients experience more negative emotions interfering their daily life, by feeling more unsecured, sad and numb. They tend to distant themselves from the society and disconnect them from the social life, including spending time with their friends, due to the lose interest and trust issues towards the environment.

Positive emotions, such as happiness and calmness is obstructed by the guilt and shame regarding the traumatic event. Fourth symptom is feeling of nervousness, tense, fear and discomfort, which victims are prone to hyperbolize awareness in inventing illusory dangerous situations. The sudden anger leads to committing deviant behaviors such as; smoking, drug and alcohol abuse, and driving aggressively.

Art Therapy

Art therapy can be the containments for clients who did not fulfilled one of their developmental stages. (Robbins, 2001). According to the recent brain research, nonverbal treatment modalities such as art therapy can treat disrupted early attachment with the primary caregivers. Also corresponding the affective tasks with the right brain, which can be organized non-verbally. (Malchiodi, 2003). Therefore, art therapy can treat the disturbed developmental stages that caused them to be more prone in being physical abuse, which leads to PTSD. However, art therapy itself, can treat PTSD as well. Most importantly, art therapy treat the root of the issue, which is the disturbed developmental stage that makes the victims prone to experience PTSD as the after effect. In term of overcoming PTSD caused by teen dating violence, the art therapy trauma processing comprise six major stages of healing processes. Each stage will result a psychological improvement of the trauma experienced. Through undergoing all of the stages, the victim have a tendency of reducing the suppression from the traumatic experience, or to some extent PTSD can be overcomed.

The first stage is called as the Trust Building, where the therapist and client establish trusting relationship that is built upon safe, non-judgemental and consistent environment. The attachment is not simply a cursory glance of building conversant between client and therapist, yet an activity called ‘Scribble Chase’ drawing assessment is conducted to investigate client’s hidden personality. The second stage is Assessment, a long-term assessment phase will be conducted through ‘Projective Drawing Test’ (PDT), which is a projective personality or cognitive test, to investigate the personality, resilience and attachment of the client. The third stage is Expected Outcome/Change. The therapist make a criteria of objective from the therapy which for PTSD patients are to have better resilience and personality. The fourth stage is Discovery, Realization and Acceptance which is consist of three drawing activities.

First, Draw your superhero (DYSH) to discover patient’s strengths and improve the resilience. Client elaborate the strengths of the superhero, which reveal their needs in improving their resilience. Second, Draw your victories to develop the patient’s self-esteem by creating a collage cutted out from magazines. Third, Draw your mother to help the victim to get closer and remember their caregiver as important persons the fifth phase is the PTSD healing processes which consists of two drawing activities and one counseling session. First, Draw your safe place to help them to find a way to be calm, focus and learning to maintain that calmness from images of the safe place. Second, Draw your support system to enable PTSD victims to feel more secure and loved surrounded by people who can support them psychologically and physically. The fifth phase is Acceptance which the victim is encouraged to accept the things that happened by forgiving the perpetrator. Last stage is Ending and Independence as the therapist gives a token of appreciation as the remembrance of him. The client must be confident of themselves and to gradually stop depending on the therapist’s help. Analysis: The extent to which art therapy in overcoming PTSD caused by the physical abuse in adolescence romantic relationship.

Each PTSD art therapy phase will result in psychological improvements regarding the victim’s core problem. To an extent, art therapy may reduce the impact of PTSD, however, to another extent art therapy may overcome PTSD. Trust between the therapist and client must be built in the Trust Building stage. The two-way scribble drawing involves the client and therapist to create a scribble together, as the client is expected to develop rapport through undertaking four levels of ETC. The first level involves kinesthetic and sensory, which is emphasized through the scribble drawing task. The therapist begin to draw a line with a marker, and the client follows the scribble path with their own marker. To develop the sensory experience, the activity may be supplemented with the companion of music. The second level involves perceptual and affective, which is emphasized through finding the images within the scribble drawing. The third level involves cognitive and symbolic, emphasized through explaining the meaning of the images, after finishing the illustration.

Lastly, creativity is assessed throughout the whole artistic process. If the client redraw the scribble initiated by the therapist with strong and bold lines, the client begin to build rapport relationship by trusting the therapist’s guidance and companion in developing her mental state. If the client does not follow the line properly, and draw dashed lines, the client is not mentally ready for further treatment, since they haven’t build rapport with the therapist. Trusting relationship building process took a lot of therapy sessions, which may varies until months, especially for PTSD victims, whom experienced drastic changes in their life. Rapport is a significant element to built in order to evaluate an individual’s personality.

Through the second stage, Assessment, the mental issue (PTSD) and the root of the problems (low-self esteem and insecurity) will be discovered. According to Neale and Rosal (1993), as a part of art therapy; projective drawing task is characterized as functional in assessing particular mental problems and provide treatment for further steps in improving one’s mental state which are Draw A Person (DAP) investigates the personality of the client, which overviewed the root of the problem that must be treated. Client is expected to present themselves, through illustration the facial expression, body language, line quality, materials used, color and participant’s description of the drawing. Through this activity, the therapist will be able to understand how the client unconsciously perceive themselves. At the end, it will present the client’s self-concept, personality and somatic issues. PTSD patients frequently experience low-self esteem and insecurity as the source of trigger. After drawing the person, client will be asked to discuss the thoughts and feelings of the person drawn.

Next, Draw A Person in The Rain is a part of the general DAP assessment that evaluated an individual’s resilience, which indicate how the client unconsciously perceived themselves in encountering internal and external conflict. Usually PTSD victims, draw the person on the right corner, without any depiction of rain gear, which evince their insecurity as the root of the problem. The rain symbolizes the problem, and the exclusion of rain gear symbolizes their lack of anticipation towards conflict prevention and resolution. PTSD victims have low resilience, therefore they had lack of capability in anticipating and fighting problems. According to Bonanno (2004), resilience is the ability to maintain a normal equilibrium state in the exposure of adverse circumstances.

Unlike strong resilient individuals who are able to restrict sympathetic activation to an extent of threatening situations, PTSD victims can’t control their sympathetic activation. Bird Nest Drawing is an art based assessment that was developed to evaluate one’s attachment security and internal representation of self and the environment (Kaiser, 1996). According to Kwiatkowska (1978), drawing a family can be threatening to some individuals. Thus, Kaiser established a less threatening form of therapeutic illustration that describes ‘family’, through illustrating a bird nest. The illustration of a bird’s nest is considered as an innocuous task, which may provoke an inclusion or exclusion of the unification of the physical nature of the nest, the nurturing figures, the fate of eggs and baby birds. Avoidant attachment with Low-ATM tend to exclude the base of the nest (root or tree). The nest are tilted, which makes it unable to secure the contents of the nest.

To some extent the nest is drawn unsecured, thin and untight nest, and not the entire bird family is depicted in the nest. The bird family symbolizes their closeness to the family and the caregiver figure. Afterwards, the therapist rate the attachment level through the Attachment Rating Scale (ARS), according to the scale of 1-5. One is the lowest score, which indicates the avoidant attachment, three is the middle score, which indicates the ambivalent attachment, and five is the highest, which indicates the secure attachment. The therapist need to reflect on the artwork and the attachment theories by questioning, ‘are the contents within the nest?’, ‘does the environment looks supportive?’, ‘does the story about the nest reflect a theme of security or attachment’, ‘does the caregiver figure included in the nest?’, and ‘how sturdy is the nest’. After the completion of each drawing, client is initiated to describe the drawing to validate the therapist interpretation of the client’s artwork.

Conclusion

There is a tendency, that PTSD caused by TDV can be managed through the art therapy processes, once the phases are practiced accordingly to the steps. Now to answer the research question of “To what extent can art therapy treat PTSD due to physical abuse in adolescence romantic relationship?”, in answering the question one must understand the causes of TDV, the characteristic of PTSD caused by TDV and art therapy processes. Both patient and therapist must understand that TDV may be caused by early attachment with the caregivers, the perpetrator’s expectation and victim’s lack of self-defense.

PTSD is mainly characterized by low self-esteem and low resilience which cause trauma, depression and social problems. However, to treat PTSD with art therapy, the therapist must acknowledge the core of problem, which is the early attachment with caregivers. First of all therapists will evaluate their state of mental wellbeing, then treat the problems. Fixing attachment with the caregivers, increasing self-esteem and resilience are the main objective to create a strong foundation of PTSD management. In the end, to some extent, the victims will be able to increase their self-esteem and resilience, and forgive the perpetrator in relieved.

This study is related to art, which makes it a big limitation since the psychology behind art is a new area of psychology that has lack of experiments to support the theories and findings in terms of managing mental problems in developmental psychology. However, in the modern era, a lot of people are looking up to find mental help through art therapy, due to the feeling of relieved they can obtain by participating.