Art Therapy with Adults and Older Adults — Phased Trauma Treatment, New Understandings of Grief, Life Review and Dementia

This chapter is general information for learning. If trauma or loss is breaking down your daily life, please get professional help. If you are thinking about harming yourself, contact your local emergency number or a crisis line right away (in the US, call or text 988).

Adult trauma: working in phases

The psychiatrist Herman (1992) described trauma recovery in three stages.

1. Establishing safety: first build stability in the body, daily life and relationships.
2. Remembrance and mourning: once safety is in place, work with trauma memories and grieve losses.
3. Reconnection with ordinary life: build new relationships and meaning.

Art therapy follows the same order. In the first stage, drawing a safe place, working within set frames and using controllable materials build stability (see media choice in Chapter 2). Asking someone to draw the traumatic scene before they are ready risks retraumatisation.

There are also attempts to combine art with evidence-based trauma treatments such as EMDR. Few studies have yet tested such integrated approaches themselves, however, so it is safer to use art as a supporting tool that respects the framework of proven treatments. The evidence on trauma treatment more broadly is covered in understanding psychotherapy through research.

Grief: beyond stage models

Kübler-Ross’s (1969) five stages — denial, anger, bargaining, depression and acceptance — originally came from interviews with dying patients. The model spread widely as it was applied to bereavement in general, but research paints a different picture.

• Stroebe, Schut and Boerner (2017) warned that there is little evidence that grief proceeds through set stages in order, and that the model can make people feel they are “grieving wrongly” when they don’t fit the stages.
• The dual process model (Stroebe & Schut, 1999) describes healthy grieving as oscillating between a loss orientation, dwelling on the loss itself, and a restoration orientation, adapting to a changed life.
• The continuing bonds perspective (Klass, Silverman & Nickman, 1996) holds that carrying on the relationship with the deceased in a new form, rather than severing it, can be part of healthy grief.

In art therapy, work that expresses the bond — such as a memory box for the deceased or a letter-drawing to them — can be alternated with work depicting a changed daily life.

Older adults: life review and legacy

The geriatric psychiatrist Butler (1963) argued that the life review older people undertake is not a morbid preoccupation but a natural, meaningful process of putting a life in order and integrating it. It connects with the task Erikson assigned to old age: integrity versus despair.

• Drawing a life timeline: arrange key life events in a single drawing or collage.
• Legacy projects: make works to pass on to the next generation, such as a picture book for grandchildren or family recipe cards.
• Sensory accommodation: prepare thick tools, large paper and high-contrast colours with eyesight and grip strength in mind.

Dementia and art

Even as dementia progresses, abilities to create and appreciate art sometimes remain relatively long. Familiar materials and repetitive movements can reduce anxiety and offer a channel of expression for people who find verbal communication hard.

The evidence, however, is still limited. A Cochrane systematic review (Deshmukh, Holmes & Cardno, 2018) examined two studies of art therapy for people with dementia and concluded that there was not enough evidence to judge effects on cognition, depression or quality of life. It is therefore more accurate to see art activities not as a treatment that slows dementia, but as activities that protect enjoyment, dignity and relationships.

Closing the course

This course has covered the history and theory of art therapy, materials, assessment, techniques and applications across the lifespan. Two messages have recurred throughout. First, art is a powerful route to experiences that words struggle to reach. Second, the evidence for its effects is still accumulating, so drawings should not be used like diagnostic tools, nor should art therapy replace well-established treatments.

Check questions

Question 1. In a first session with an adult client one month after a car accident, the therapist asks, “Please draw the scene of the accident.” In light of Herman’s stage model, what’s the problem?

Answer. It jumps straight into memory work without the first stage, establishing safety. With a risk of retraumatisation, work that builds stability — such as drawing a safe place — should come first.

Question 2. A client who has lost their spouse asks, “I haven’t gone through the anger stage yet — is that OK?” How might you respond?

Answer. There is little evidence that grief moves through set stages in order. You can explain, as the dual process model suggests, that moving back and forth between time spent with the loss and time adapting to daily life is a natural process.

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References

• Herman, J. L. (1992). Trauma and Recovery. Basic Books.
• Kübler-Ross, E. (1969). On Death and Dying. Macmillan.
• Stroebe, M., Schut, H., & Boerner, K. (2017). Cautioning health-care professionals: Bereaved persons are misguided through the stages of grief. OMEGA—Journal of Death and Dying, 74(4), 455–473.
• Stroebe, M., & Schut, H. (1999). The dual process model of coping with bereavement: Rationale and description. Death Studies, 23(3), 197–224.
• Klass, D., Silverman, P. R., & Nickman, S. L. (Eds.). (1996). Continuing Bonds: New Understandings of Grief. Taylor & Francis.
• Butler, R. N. (1963). The life review: An interpretation of reminiscence in the aged. Psychiatry, 26(1), 65–76.
• Erikson, E. H. (1982). The Life Cycle Completed. Norton.
• Deshmukh, S. R., Holmes, J., & Cardno, A. (2018). Art therapy for people with dementia. Cochrane Database of Systematic Reviews, 9, CD011073.