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Short-term Group Art Therapy with outpatient Eating Disorder

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on 9 February 2016

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Transcript of Short-term Group Art Therapy with outpatient Eating Disorder

Short-term Group Art Therapy
for Outpatient Adolescent Clients
with Eating Disorders

First Session:
Emotions Circle
Fourth Session:
Collage Mask-making
Fifth Session:
Recovery Anchors
But Challenges Can Arise...
Third Session:
Group Mandala
Sixth Session:
Past, Present and
Future: Metaphor of Self
Seventh Session: Safety/S
upport Box
Final Session:
Support/Grounding Trading Cards
Second Session:

Feelings Mandala
Improve self-concept, self-awareness
and further identity formation, increase awareness of feelings

Increase social support for
continued recovery
Increase healthy functioning in relationships
Decrease social isolation

Reduce body judgement and body image distress
Group Cohesion
and Composition
Assessment of the Clinical Situation
Allow clients to open up and feel comfortable expressing self in a group setting. Establish rapport/trust with therapist and group members.
Group expectations.
Feeling emotions. Finding voice.
Therapy techniques:
Opening and closing ritual.
Probing questions:
Where in his/her life is client experiencing these emotions/feelings?
What does this emotion feel like?
Stage of group:
(Dependence on leader is high.
Desire for acceptance.
Conflict avoidance).
Process and release emotions (i.e. stress/anxiety, fear, etc). Decrease perfectionism. Increase free creative expression.
Give voice to current feelings.
Letting go of control?
Emotions/feelings. Healthy expression.
Therapy techniques:
Opening and closing ritual. Discussion of "acting as if."
Probing questions:
Can you name the feeling/emotion associated with the created image? Where is your safe place to express this emotion? What are healthy ways to validate theses feelings?
Stage of group:
(Clients begin to take risks. Sharing becomes
more free flowing).
Increase group cohesion. Develop voice. Increase sense of community.
Boundaries and connection through interpersonal communication.
Therapy techniques:
A version of the carousel activity (clients move from station to station, building on each other's work).

Opening and closing ritual.
Probing questions:
How was it to engage in a group project? What did you notice about your personal strengths and limitations with communicating your needs? How were you challenged?
Stage of group:
(Individual group roles are defined. Challenges and conflicts arise).
Facilitate self-reflection, self-identification, self-awareness. Integrate inner and outer self images.
Self-awareness. Body image.
Media's visual representations/expectations.
Identity outside of the eating disorder.
Therapy techniques:
Free association.
Opening and closing ritual.
Probing questions:
What are the differences between your inner and outer surfaces? How can you reconcile these two? Which are you more comfortable with? What impact does your "mask" have on your road to recovery?
Stage of group:
(Group cohesion and creativity are high).
Increase communication, trust and safety within the group. Identify support systems available
Support systems. Healthy and appropriate boundaries.
Therapy techniques:
Coping skills. Opening and closing ritual.
Probing questions:
What anchors you? Who are the anchors in your life? Who or what provides you stability and strength?
How can you be a support to those around you?
Stage of group:
Norming (Sharing is common. Client's give feedback to one another).
Encourage decision making skills. Freedom of choice. Increase client’s self-awareness. Encourage self-acknowledgment for accomplishments through the creative and healing journey. Experience increased self-esteem. Stimulate reflection. Visual representation of the client's desired future/changes may
help create change in thoughts.
Facilitate discussion regarding recovery goals, struggles, realistic expectations, and what it will take to be successful in reaching goals (self-care).
Therapy techniques:
Opening and closing ritual. Explore life style, investigate mistaken beliefs.
Probing questions:
How have your experiences impacted one’s self? In what ways have they influenced your self-esteem, self-image,
self-confidence or self-doubt?
Stage of group:
Norming (Group morale is high).

Increase client's sense of self-worth and value. Connect with others. In healthy ways
share common experiences.
Support. Grounding and centering.
Therapy techniques:
Coping skills. Social skills. Opening and closing ritual.
Probing questions:
How do you find support? How do you recognize when you need to reach out to others for help?
Stage of group:
(Group unity and loyalty).
Create freedom through visual expression. Express individuality.
Grounding/Support reminders. Group connection. Healthy goodbyes.
Therapy techniques:
Coping skills.

Opening and closing ritual.
Probing questions:
How would you describe your journey through this group? What is one thing that you can take from this group?
One thing that your are grateful for?
Stage of group:
(Disengagement process).
Role of Leader/leaders
What Themes, Archetypes, Symbols,
Metaphors Appear?
Adlerian Techniques Used in Processing the Art
Eating disorders are very isolating
Clients experience a great deal of shame
Clients may lack the ability to recognize and
voice emotions and feelings
Detached from their body (The ‘mind-body split’).
Tend to think of body as an enemy or as a separate entity
Clients typically present with (a) coexisting
mental health diagnosis(es)
(Anxiety, depression, chemical dependency, trauma, etc.)
Clients struggle with perfectionism and
the desire to be in control
Self denial
The group is designed to be part of a step-down care plan for clients who have recently discharged from a residential eating disorder treatment program. A referral from a residential treatment team is required.
The additional support received from participation in a group has proven beneficial to increase the likelihood of recovery.

Clients must commit to be actively engaged in all treatment recommendations at the outpatient care level. Treatment recommendations may consist of all/or any of the following services: individual therapy, family therapy, nutritional counseling and medical/psychiatric follow-up appointments.

The group composition is adolescents, ages 12-18 with an active eating disorder diagnosis of: Anorexia Nervosa, Bulimia Nervosa, Compulsive Overeating, Binge-eating Disorder, EDNOS.
Colored pencils, markers, crayons and a sheet of paper.

Draw a circle on the white sheet of paper.
Divide the circle into equal sections (6-8). Label each section with an emotion and then color/design the section to reflect that emotion. Once finished, journal about why you choose the color or explain what the picture means. Allow opportunity to share as it feels comfortable.
“Art therapy has been found to be extremely effective with clients with eating disorders, as it facilitates greater awareness of thwarted needs, desires, and distresses and provides simultaneously, a metaphorical and concrete outlet for expression that promotes a greater emotional vocabulary, both visually and verbally. It is a way to meet clients where they are, in an honoring way.”
(AATA - Michelle L. Dean, MA, ATR-BC, LPC, CGP, DVATA HLM)
Watercolor or acrylic paint and cardboard.

Draw a circle on the piece of cardboard. Focus on how you are feeling today. How do you feel in your recovery? Paint that feeling. Once finished have the client explain the created image and how it relates to their journey in recovery. Continue to dialogue as the client feels comfortable.
Chalk and butcher paper or sidewalk (depending on weather).

Group leader will draw large circle with individual smaller circles drawn around the large central circle. Clients will work on an individual smaller external circle. Once each client is completed with their personal mandala, clients will engage as a group to create a large group mandala. Subject matter open to the discretion of the group.
Mask, magazines, or any available studio media, decoupage.

While reflecting on self, decorate the surface any way you like with any media. After finishing the outer surface, spend some time thinking what is "behind your mask" and complete the interior surface.
2.5"× 3.5" cards made from card stock, markers, glitter glue, paint sticks, magazines, etc.

Create images (number of cards dependent on number of clients in group) of your best moment(s). Focus on the use of color and shapes with limited imagery. On each card write down an inspirational message (saying, quote, poem, etc). Once everyone has finished, trade with one another until each group member has a card from everyone.
Box, paper, markers, glitter glue, paint sticks, magazines, etc.

Collage or paint a box the represents you and/or your journey through recovery from your eating disorder. Then, fill the inside the box with items that represent the things that you love, create safety and support.
Pre-cut anchor shapes, markers, paint, magazines, scissors.

Hold a group discussion around the purpose of an anchor. Draw, paint, collage or write what anchors you (gives you support) within the design. Share and discuss each image/response. Talk about new places you may find strength or how to strengthen current avenues of support.
3- 8x10 (or smaller) art canvases, any 2-dimensional media.

Using three separate canvases, metaphorically draw or paint where you have come from, who you are, and how see yourself in the future. There is no right or wrong way to create these images. Try to stay away from realistic representations.
If the client becomes medically compromised, showing an inability to function in outpatient treatment. It then becomes necessary to begin discussion about a re-admit to residential treatment to stabilize health.

An individual client's symptom use becomes triggering to others within the group.

Certain clients dominate the group. Often times regaining an active 'voice' is a part of the treatment goals for clients struggling with eating disorders, therefore it is essential to make sure all member's are being heard and feel comfortable voicing opinions (encourage participation from those who are hesitant - provide equal community involvement).

Co-existing mental health problems present more clinically significant than the eating disorder diagnosis. These conditions may be triggering the eating disorder behavior(s). Addressing other mental health concerns may need to take precedence.

Explore client's private logic, concept about self, others and life.
Life style assessment: In process, the client finishes
the following statements:
I am ______________.
Others are ______________.
The world is ______________.
Therefore, in order to belong,
I _______________________.

Then have clients change the above statements into positives,
create realistic goals.

Therapist can offer open-ended interpretations. Discover, identify and confront the purposes of behavior, feelings, or symptoms. Look into the mistaken beliefs associated with current coping mechanisms.

Learn how to correct faulty assumptions and conclusions about self and others. Encouraging development of self.

Help clients make new choices - reorientation & reeducation.

Social interest: The very nature of being in a group and
establishing community is Adlerian.

Encourage clients to engage with others and move away from the
isolating nature of the eating disorder.
The eating disorder becomes personified
Stereotyped or safe symbols (For adolescents this could include crosses, roses, peace sign, hearts, etc) - symbols that feel safe or images that clients are comfortable drawing, as it provides a safe/non-judgement introduction to art making.
During the first group session leader/leaders must explain that there is no right or wrong in what is created. Within the group setting there will be no judging based on "standardized measure of talent, beauty, or success" (Schwartz, D). Respect and appreciation for individuality is essential to the success of the art therapy group. The focus of the group is on the process of creating and not the finished art. Session one will focus on clients getting to know one another and familiarizing themselves with group expectations and norms.

The flow of the each session is designed to encourage clients, through creative expression, to explore self-identity and recognition, trust amongst all members and community engagement. Emphasis is also placed on addressing faulty cognition in a safe contained space.

Each session builds upon the previous creating a mixture of directives that reinforce exploration into oneself, while also fostering a sense of connection to those who have similar struggles. Client are eased into visual expression and expressing their emotions. Group interaction is increased as the sessions move forward.

At the conclusion of the group, clients will have insight into themselves, possess a visual record of their journey and acquire tools they can access on their own to help ground themselves and process thoughts and feelings. The images/art created will serve as visual reminders of their progress and offer continual support.
Above all, group leader/leaders must have the relevant experience and
training both in art therapy and treatment of eating disorders.

Critical to the success of the group, the leader/leaders must:

Have knowledge of crisis assessment and intervention, especially with suicidal and substance-abusive adolescents.
Understand group dynamics.
Have knowledge of normal adolescent development - cognitive and emotional changes that take place during adolescence.
Complete training or have familiarity in Adlerian and cognitive-behavioral therapies
Have experience leading psychotherapeutic groups, especially with adolescents and/or children.

Group Recap...
American Art Therapy Association. (2012).
Art therapy’s notable impact on eating disorders and healthy eating
. Retrieved from http://www.americanarttherapyassociation.org/

Belangee, S. (2012, July 1). Individual psychology: Relevant techniques for today’s counselor.
Counseling Today
. Retrieved from http://ct.counseling.org

Capacchione, L. (1989).
The creative journal for children: A guide for parents, teachers, and counselors
. Boston, MA: Shambhala Publications.

Clarke, G., Lewinsohn, P., & Hops, H. (1990).
Leader’s manual for adolescent groups: Adolescent coping with depression course
. Retrieved from http://www.kpchr.org/

Corey, C., & Corey, M. (2014).
Groups process and practice
. Belmont, CA: Brookes/Cole.

Daily-Murphy, L. (2006). Helpful tips for after residential treatment.
Eating Disorders Recovery Today, 4(4).

Malchiodi, C. (Ed.). (2013).
Art therapy and health care
. New York, NY: The Guilford Press.

Schwartz, D. (2014, March 21). Expressive arts therapy and eating disorders. [Web log comment]. Retrieved from http://www.nationaleatingdisorders.org/expressive-arts-therapy-and-eating-disorders
"Sometimes, the more we intellectualize through talk, the more the split between our thoughts and feelings widens. When we shift to a more “right brain,” creative approach and engage in art, movement, drama, etc. the door opens for client to shift from explaining their feelings to actually feeling them. In that moment there is a tangible body experience of how feelings affect them, and a safe place to explore ways to manage those feelings."
(Dr. Deah Schwartz)
Session 1 provides clients an opportunity to gently explore feelings while also introducing them to the creative process. By session 3, clients are asked to directly interact with one another through the art directive to create one large artwork. Group dynamics, especially group roles emerge and clients begin to explore boundaries and problem solve - using social skills that will help them during their recovery from the eating disorder and also throughout life.

As clients proceed through the remaining weeks, they work both individually and cooperatively while being gradually exposed to directives that challenge current faulty beliefs ("I must be perfect," "I am never good enough," It is best that I not be seen," etc) in a supportive environment. Clients are encouraged to respectfully challenge one each other's destructive beliefs and offer feedback.

Throughout the sessions, clients are asked to engage in group art-making as well as discuss their work openly as the sessions move forward. Central to this group is the Adlerian belief that healing happens when we are in community and when we invest in and offer help to those around us.

Through creative expression and group processing, the hope is that clients begin to move away from destructive beliefs and find support and healing through creative expression AND a deep connection with others.
Recap Cont....
Be Respectful and encouraging
Be present and engaged
Be Mindful
Be a Good Listener
Be Supportive
Be Safe and keep confidentiality
Be invested in your recovery and
Trust the process!
Group Norms and Agreements
Changes to disordered eating patterns become possible when underlying issues/conditions are addressed/resolved, especially those involving relationships and
personal communication.
Post Residential Treatment:
The Transition to Outpatient Care-
Helpful Tips for Continued Recovery
(Laurie Daily-Murphy,
Eating Disorders Recovery Today

Admit your need for help
Check in with a friend/family member
Follow a regular recovery schedule
Meetings and Support Groups:
Attend groups even when it is difficult
"Reaching out breaks the shame and isolation"
Be willing to feel
Therapy & Treatment Team:
Treatment always needs to be a priority
Emotional Needs:
Find a healthy way to get your needs met
Set limits and practice them
Explore what brings you joy, hope and connection
Help others
Spend time with others. Don't isolate
Create - express yourself!

Healing Journey:
Creative Expression
Healing Journey: Creative Expression
is an 8 week long art therapy group -
each session is 2.5 hours
Healing Journey:
Creative Expression

Please note: ALL depicted artwork is not client produced. All artwork pictured created by Lisa Atkinson to provide visual examples of
each art directive.
-Lisa Atkinson-
Full transcript