The Use of Art Therapy in Treatment of Attachment Disorder
Marilyn Magnuson MSW, RSW
Attachment disorder results from a lack of secure attachment to a loving and nurturing caregiver, especially during the first three critical years. The number of children in care with severe attachment disorder is directly related to an increase in parental conditions of addiction, abuse and neglect (Gonick & Gold, 1992). Foster and adoptive parents may become traumatized during their attempt to parent children with disrupted or anxious attachment. "Such children are unable to give and receive love and affection, constantly defy parental rules and authority, are physically and emotionally abusive to caregivers and siblings, and create ongoing stress and turmoil in the family" (Levy, 1998). Adoptive and foster parents may 'give up,' resulting in multiple foster placements that increase the severity of behavioural symptoms.
Disrupted and anxious attachment leads to emotional and social problems, and affects the developing brain. Symptoms of attachment disorder can be (Levy, 1998):
superficial and charming engagement; lack of eye contact on parental terms
indiscriminate affection with strangers; not affectionate on parent's terms
destructive to self, others, and material things (accident prone)
cruel to animals
lying about the obvious (crazy lying)
no impulse control (frequently acts hyperactive)
lack of cause-and-effect thinking
lack of conscience
abnormal eating patterns
poor peer relationships
preoccupation with fire
persistent nonsense questions and incessant chatter
inappropriate demanding and clingy behaviour
abnormal speech patterns
sexual acting out (Levy, 1998).
After birth the brain functions largely from the brain stem and Limbic system (old brain) that regulate body functioning, stress-provoked responses, imitative behaviours, and adaptation. The Limbic system maintains the immune system as well as development of relationship bonds through the experience and expression of emotions (attachment behaviour). Infants with anxious or disrupted attachment have abnormally high levels of stress hormones that can impair growth and development. As the Cerebral Cortex (new brain) develops it governs production of symbolic language, decision-making and information processing, and is believed to regulate the higher emotions of empathy, compassion, and love. Disrupted and anxious attachment reduces cerebral cortex development, resulting in reduced or abnormal intellectual, emotional, and social maturation. This includes "impaired conscience development, trouble with basic cause and effect awareness, impaired sense of time, and difficulty with auditory processing" (Gonick & Gold, 1992). These children are in a constant fight-or-flight response, demonstrating aggressive and manipulative behaviours and a lack of empathy for others. Difficulty with verbal expression and fine and gross motor skill development may occur. "They may push love away due to lack of trust, expectation of maltreatment, and an unconscious attempt to recreate prior negative attachment patterns" (Levy, 1998). In addition to impaired brain development, traumatic experiences and memories are held in body tissue, further impacting psychological and physiological functioning (Pert, 1997).
The Use of Art Therapy in Treatment
Children often have difficulty speaking about their concerns, feelings and past trauma, but they can draw and paint these images through art therapy. Art Therapy makes use of symbols and images as an alternative language. Memories, emotions, desires and concerns are externalized and released from body tissue through the art. Once a therapeutic environment has been set, art therapists 'get out of the way' while art makers relax and use their intuition to guide their artmaking. Art materials such as clay, paints, pastels, and markers provide visceral stimulation, brining body memories to the conscious. These images from the unconscious reveal hidden aspects of Self. By tapping into right brain activity through spontaneous artmaking we by-pass the judging, censoring and rationale left-brain. Art therapy is useful for children who experienced trauma prior to speech, as they do not have words to express the trauma, but the symbolic memories remain in the old brain. For example, this girl drew her hospital experience as an infant. Through the doorway (left vertical line) she saw the nursing station and the emptiness of the experience (sparse lines), and her separation anxiety (where's mom?). These Limbic memories do not appear during talk therapy.
Family involvement in treatment is essential. This usually begins with family art therapy assessment exercises, as well tools to uncover intergenerational history (Genogram) and community supports (Ecomap), and a behavioural questionnaire. The Kinetic Family Drawing (KFD - Landgarten, 1987) requires all family members to draw on the same page without speaking. They then draw together on a separate page while speaking to one another. The resulting drawings reveal family dynamics that assist in developing therapeutic interventions (Gil, 1994).
This six-year old boy, Billy, was brought to therapy for aggression, nightmares, learning problems, and lack of social skills. Family history disclosed that Mom gave birth at age 16 while living with the father and his parents. Although they moved out of the grandparent's home when Billy was 2 years old, Billy often stayed with Grandma, and learned to phone Grandma when there were domestic problems. Grandma then would rescue him. Mom and dad were emotionally, verbally and physically abusive to Billy. Mom was overwhelmed and Dad was in need of psychiatric care for depression and anxiety. Billy appeared insecurely attached and was afraid of his parents during stressful times. Neither Mom nor Dad had a history of secure childhood attachment and found it difficult to nurture him physically and emotionally.
The non-verbal family drawing was started by Grandma who took up much of the space on the page with her sun and tree. She encapsulated herself and Billy in a tree. Billy drew dad with rabbit ears, possibly a symbol of dad's ineffectiveness. He drew mom with hair on her legs and a large razor, possibly symbolizing mom's aggressiveness. He drew a sun in the upper right corner, copying Grandma, and pushing dad over to the middle of the page next to mom. It appeared that his desire was for his parents to get along. Dad drew a sword stuck in a rock, possibly symbolizing his emotional state. Mom drew herself and dad as separated from the two boys.
The verbal family drawing began with Grandma taking over mom's space, pushing her out of the activity, possibly symbolizing Grandma's rivalry with Mom, and Mom's disempowerment within the family. Billy again demonstrated his anger with mom by giving her a bat that resembled a knife. Dad drew his brother as a humorous character Grandma drew Grandpa as small and stated he was rather uninvolved. The black oval object is a garbage can that Billy included, possibly symbolizing his view of family nurturance. Mom was left with no room to draw and solved this problem by placing grass under the feet of each figure. The family drawings demonstrated triangulation and coalitions. Grandma appeared to be matriarchal and protective, triangulated with Billy. The couple relationship appeared to be stressed, and Billy appeared to be both angry and afraid. Within an hour family dynamics were revealed through art images and the processing of these images.
During art therapy sessions children and parents externalize concerns, desires, memories and emotions. A single parent mother and her two daughters aged 9 and 6 created the following images. Mom spent most of her childhood in multiple foster placements and was alcoholic. The children experienced multiple foster and extended family caregivers since birth. Attachment disorder is transmitted intergenerationally as parents are incapable of establishing this crucial foundation with their own children. This mother openly and verbally rejected the oldest daughter, stating she reminded her of her abusive ex-husband. The daughter appeared to cope by continually seeking Mom's attention through negative behaviours (an approach-avoidance position). She was abusive to her younger sister and demonstrated many symptoms of attachment disorder. The oldest daughter recently returned to mom after spending two years with her natural father, and before long both children entered foster care again. Mom came to art therapy, using it as a means to enjoy visitation with her daughters while working on strengthening her relationship with them. The family was to be reunited within a month. Mom and the girls made images to express their feelings about being separated.
They also created images of a desire to be together and what that might be like. Mom made a portrait of each girl, and the girls drew their mom and each other. Mom increased her sensitivity to her daughter's feelings of rejection, increased parent-child communication, and worked at appropriate limit setting and consequences with the assistance of the therapist. During sand play the family explored their extended family to determine who was safe, who was a threat, and who could support them. In the last session they build a house and yard together, symbolizing reunification.
The use of expressive arts therapies combined with traditional psychotherapeutic approaches strengthens treatment success (Gil, 1994; Levy 1998). In verbal therapy these children displayed lack of trust, lack of cooperation, and difficulty with abstract concepts. Art and play therapy are fun, creative and less threatening (Gil, 1994). Art images are powerful beyond words, releasing tensions and traumatic memories. Themes are brought to the surface that may otherwise lie dormant, and reflect the child's needs for safety, security, and competence (Gonick & Gold, 1992). Treatment interventions assist the child and family to re-create elements of secure attachment that were unavailable in the child's early developmental stages (empathy, positive affect, support, reciprocity and love). It includes the celebration of achievements, cementing positive changes, and enhancing hope for the future. Studies demonstrate that children with attachment disorder can learn to believe in themselves and overcome trauma.
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Gonick, R.S. & Gold, M (1992). Fragile attachments: expressive arts therapy with children in foster care.
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Karen, R. (1998). Becoming attached; first relationships and how they shape our capacity to love. New
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Levy, T.M. (1998). Attachment, trauma, and healing: understanding and treating attachment disorder in
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Pert, C. (1997). Molecules of emotion; the science behind mind-body medicine. New