Group Art Therapy/Psychotherapy at the Canadian Center for Victims of Torture By Dr. Abbas Azadian, M.D. and Mary Sanderson R.C.A.T.
In the fall of 1999, The Health Committee of the Canadian Center for Victims of Torture approved as a pilot project, an Art Therapy/Psychotherapy Group for our clients. The Group was co-led by Dr. Abbas Azadian, and Art Therapist Mary Sanderson.
1. In the first session, each participant was invited to portray themselves as a tree. A woman from the former Yugoslavia painted this strong, healthy apple tree, laden with fruit. She said it represented her vitality and hope for her new life in this country. She was very proud of this tree.
2. Several months into the group, the woman learned she had been refused refugee status. She painted this picture. The beautiful healthy tree has been uprooted, the green leaves are gone, the fruit is no where to be seen. The tree looks dead. It is lying, abandoned on the beach. The one sign of hope Is the single apple on the beach. The woman identifies this as her teenage daughter who is in the former Yugoslavia. Her daughter is the pride and joy of her life.
3. Several weeks after painting the second picture, the woman learned that she will not be allowed to appeal the Refugee Board decision. She is devastated. Now she portrays her tree at the bottom of the lake, totally abandoned. On the surface of the water is a boat. She identifies this boat as that of the Immigration Board. They are out looking for her. Still, her single apple remains bobbing in the water, a reminder that her daughter is still alive.
4. In the last session of the group each participant was asked to portray their tree again, as a way of assessing what had happened to them during the 6 months of the group. This woman at first said she couldn't draw anything, then she picked up a paint brush and painted this picture. Her tree is being consumed by flames. The apple has disappeared.
Background
The vast majority of our clients suffer from psychological effects of trauma and torture. These include a triad of post traumatic stress symptoms: hyperarousal with anxiety, insomnia, startle reaction or jumpiness; re-experiencing the traumatic experience with nightmares, flashbacks, recurrent images or thoughts; and avoidance of social and personal interaction as well as the avoidance of any thoughts or feelings reminding the person of the trauma. Depressive symptomatology in such circumstances is related to the loss of relatives and friends. In the case of refugees and refugee claimants, there is the added loss of social position and community, which they have not yet achieved in their new country. Women and children are especially at risk of Post Traumatic Stress Disorder (PTSD) following political violence. Women are attacked because of their sexual identity. Providing treatment to this population is challenging and has inherent limitations:
Limitations of work with torture victims:
1. For obvious political reasons, most torture victims who are seen for treatment do not live in their home country, which is usually where the torture occurred. Because of this, most victims have only a limited knowledge of the host country's language. This affects their adjustment and limits their use of psychotherapy. Some therapists regularly use interpreters. This is a reasonable solution but has its own inherent problems. An interpreter may affect the therapeutic alliance, and/or may limit effective communication between patient and therapist by creating artificial distance between them. As well, misunderstanding can more easily occur through misinterpretation.
2. The language problem may make the cultural differences between patient and therapist appears more extreme than it really is.
3. Survivors of trauma have difficulty expressing their emotions. Expression of feelings becomes even more difficult when there are language problems and cultural differences.
4. Traumatized refugees are deprived of a social network of support, which has been shown to be the most important factor preventing psychiatric illness.
CCVT has been using Art Therapy since 1992 and we have found that it addresses some of these limitations.
Benefits of Art Therapy
1. Art is a universal language and needs no interpreter. This does not mean that the "artist" cannot shed light on his or her work, and that an explanation is not important. However, often the art speaks for itself in profound ways that words could never convey. Art therapy's gentle and non-directive approach transcends verbal expression and allows the client to easily and quickly tap into issues and memories that may be blocked or unexpressed. Often the details of a torture survivor's story are unspeakable. There are sometimes no words to describe what he has experienced and even if there were, he is often unable to articulate them because of pain or shame or grief. But certain images are vivid and ever-present. It is not difficult to put them on paper or make them out of clay. And then, amazingly, it becomes possible to talk about them, sometimes in the third person. Somehow the images seem to lose some of their power.
2. Art therapy allows the client to determine what is dealt with in each session and how fast or slowly the therapist and client proceed. It is the client that decides what art materials to use and what to draw or paint and whether or not to talk about the art. Being in control, even for the length of the therapy session can be very therapeutic for someone who has been imprisoned, interrogated for hours on end and has had little control over most details of his life. The creative process itself is healing. The act of drawing, painting or making something out of clay can be life-giving and empowering. Creativity cuts through pain and anguishes and taps into the inner spirit. For many of our clients, art therapy is the first life-enhancing and creative activity they have engaged in since arriving in Canada.
3. Art therapy is a safe and natural means of expressing strong feelings. It is not enough to simply portray the details of their torture and painful past. The emotion connected with the experience must also be expressed and shared. All survivors of torture have a great deal of unexpressed emotion. Often, the victim has survived because he has been able to repress strong feelings of anger and fear. Now safe in this country, these emotions must find an outlet if healing is to take place and the survivor is to have a full life. Loss, whether physical, emotional or social, must be grieved and reconciled; anger and rage must be expressed. Human beings cannot suppress only their negative feelings. Joy and love are also constrained when grief, anger and rage are suppressed. Many women have been taught that it is wrong not only to express, but to feel anger. For a great number of torture survivors, unexpressed anger manifests itself in depression. Spontaneous art allows strong feelings to emerge when the survivor is ready to face them. Once the details and emotions of the torture experience have been faced, the survivor can begin to integrate them. What once may have been incapacitating pain can now be surmounted and the survivor can begin to develop new and healthy patterns of living.
A 1999 study of torture survivors who had individual art therapy, revealed:
1. Art facilitated communication and the expression of feeling
2. The safe and trusting environment within which the therapy was conducted contributed to a positive outcome.
3. There was improved self-understanding as a result of their involvement in art therapy.
4. The participants experienced a shift in self-perception and improved self-esteem.
5. There was a shift of attitude toward more future-oriented goals.
6. Participants found the process of creating art soothing and facilitated expression of thoughts and feelings not expressible in words.
Advantages of group therapy:
Reaction and stress related to trauma can be treated in individual or group settings. Since our Centre has had positive experience with art therapy with individuals, we wanted to try it in a group, psychotherapy setting. There were specific therapeutic factors we had in mind when we suggested a group format. Irving Yalom, who has written extensively about groups, describes fee benefits of a group format. These factors were our guidelines in our art therapy group:
1. Installation of hope. In both the pre-group orientation and in the group, we tried to reinforce positive expectations, to remove negative preconceptions and to provide as lucid and powerful explanations as possible about the group's healing properties. Observing improvement in others is obviously part of this process. We frequently called attention to improvements made both by individual members and by the group as a whole.
2. Many clients believe that they are unique in their suffering and wretchedness. This is usually heightened by their social isolation. Group therapy provides a forum where patients discover they are not alone and that others share the same dilemmas and life experiences. For many there is great relief in this discovery.
3. The therapist's clarification of a reaction or symptom in a didactic explanation as well as direct advice from other group members creates an atmosphere of mutual respect, interest and concern.
4. Many recent refugee claimants are uncertain about their future and feel demoralized. They frequently say they have nothing of value to offer to others. This misconception can be challenged and changed in the group when they offer helpful advice and encouragement to each other.
5. Social learning operates in all therapy groups. Given the narrow social context of recently arrived refugees, a group can provide an opportunity for accurate interpersonal feedback. The group also provides an opportunity for clients to model themselves on aspects of the other group members as well as the therapist.
Method
Our group consisted of about ten participants, with equal numbers of men and women. Our only criteria for admission to the group was that they be clients of the Centre, (i.e. that they were genuine torture survivors) and that they spoke and understood English well enough to be able to function without an interpreter. They reflected the diverse clientele of our Center: There were members from India, Iran, Madagascar, Nigeria and the former Yugoslavia.
We made available at each session large sheets of white paper, oil pastels, water color paints and clay. The group met for two hours weekly. Initially we allowed up to half the time for artwork but we quickly found clients needed more time to talk. This meant that clients usually completed only one or two pieces of art. The sessions were relaxed and informal, with members of the group getting up at will and finding the art materials they needed. We began each session by inviting everyone to use the art materials. For the most part, people worked quietly and often intently on their own art with little conversation. After everyone had completed at least one art piece, usually after half and hour, we would invite someone to share their art. It was a standard rule that no one should be pressured to talk about anything he or she did not want to talk about. Once the 'artist' had explained his/her art the other members were invited to ask questions or make comments. These were not limited to the 'artist' only. Others might be asked how they felt about a particular drawing or a comment that someone in the group made.
A woman from a country In West Africa identified the big fish as a person with power and authority. She is the little fish being eaten by the big fish. All the members of the group nodded knowingly and said, 'Yes, people in authority like to destroy little people.' But the woman corrected them, 'No!' she said, 'Sometimes they protect you.'
Content
During the six months the group met many issues surfaced in the participants' art: loss, separation, grief, identity, adjustment to a new society, suicide and traumatic experiences. As well, there were many issues around immigration- their status, their upcoming hearing, appeals, lawyers, etc. We also dealt with many day to day issues as they arose in client's lives.
The hearing of the Refugee Board looms large in the life of all refugee claimants, who made up the bulk of the group. They live in terror of being refused and returned to their own country. This picture portrays the feeling of helplessness and frustration that comes when someone is refused entry into this country. There is no way out. In the second picture, all roads lead to nowhere.
Case study:
K. is a 32-year-old woman who was part of our group from the beginning. She is from a country in West Africa and came to Canada a few months before the group began, seeking refugee status. At her initial immigration hearing her request was denied. She is in the process of appealing that decision. She is not working and lives alone.
K. is alone in Canada, her only friends being those she has met in E.S.L class. She scored 27 and 18 on the Beck Anxiety Inventory and Beck Depressive Inventory before the group began. This indicated a mild to moderate degree of depression and anxiety.
K. initially was reserved and did not participate in the discussion of other people's work. She used the art well, depicting, at different sessions, the relationship between authority figures and community; the boat in which she escaped with her brother piloting her to safety; her son playing with other children; the map of her country with the country's flag. Gradually, she began talking more about her own work. She started to interact with other people and to relate to their work. She became more spontaneous and vocal.
Eventually, K. felt secure enough to tell her story.
When her mother was pregnant, the family was having a very difficult time surviving. A chief from a neighboring village approached them with a proposal. He would support the family with food and money, indefinitely, if, when the baby was born he or she be given to the chief. If the baby was a boy he would work for the chief, if it was a girl, she would become one of his wives. The chief was about 40 years of age at the time and already had several wives.
When K. was born she was sent to the chief's village and did not meet her mother until she was 6 years old. K. did well in the local school and was sent to the capital city to go to college. She had a boyfriend and they were in love with each other. When she returned to the village, she learned for the first time, about the agreement with the chief. She decided to challenge this and ran away. She returned to the city and made an important decision. She and her boyfriend decided to try to become pregnant and eventually she gave birth to a healthy boy.
Nevertheless, this did not stop the chief. When it became known that K had a child, the chief and the people of the village punished her with beatings and burning. K decided there would never be any real future for her in that village and she waited for the right moment to escape from the chief, the village and a life of slavery and entrapment. Leaving her child behind and with the aid of her brother, she slipped away in a boat under cover of night and eventually found her way to Canada, where she applied to be a refugee.
This was an emotional session for the group. It prompted others to talk about how they had escaped and what they have left behind. They offered great support to K. and to each other.
At the end of the group, K. said: "I don't feel isolated any more. I know there are other people who went through the same things. That makes me feel better. I also feel safer in Canada. Before, seeing a black man would have made me feel scared. Now I know that people are safe here. All members of our group had a hard time but they are safe in Canada." She added; “My future is not clear yet but I am more hopeful about the future. Even if they don't accept my application the second time around I'll continue fighting."
The last time we saw K. she was brightly dressed and looked happy and relaxed. She completed the Beck Anxiety and Depression Inventory Tests again four weeks after the group ended. This time she scored 10 and 6 respectively. Both scores are within the normal range.
The Art Therapy/Psychotherapy Group appears to have met an important need for some of our clients. Many have expressed a wish to continue with the group when it begins again in the fall.
