“At root, a pearl is a ‘disturbance,’ a beauty caused by something that isn’t supposed to be there, about which something needs to be done. It is the interruption of equilibrium that creates beauty. Beauty is a response to provocation, to intrusion…The pearl’s beauty is made as a result of insult just as art is made as a response to something in our environment that fires up, sparks us, causes us to think differently. The pearl, like art, must be catalyzed. And we, unlike the mollusk, can invite the disturbance that provokes us into art.”Julie Cameron (2005)
According to the American Art Therapy Association (2017), art therapy is defined as, “an integrative mental health and human services profession that enriches the lives of individuals, families, and communities through active art-making, creative process, applied psychological theory, and human experience within a psychotherapeutic relationship.” Images in forms of dreams, fantasies and experience allow us to tap into our unconscious process. Through art therapy, resolution of internal conflicts and healing can take place. Clients can communicate with both images and words, without worrying about the limitations of verbal language (Wadeson, 2010). Images, too, can provide a safe container by acting as tangible and transitional objects, giving the clients space and “a bridge” to talk about a difficult experience (Wadeson, 2010). The art therapist works with clients to create a safe container for them to face trauma and difficulties, and bypass defenses, in order to facilitate healing (Seth-Smith, 1997). Many art therapy researchers believe that art therapy is useful for targeting somatic aspects of traumatic memory integrating the left and right hemispheres of the brain (Talwar, 2007).
Trauma stems from “an event, series of events, or set of circumstances experienced by an individual as physically or emotionally harmful or life-threatening with lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being” (Substance Abuse and Mental Health Services Administration, 2019). Cultural trauma impacts members of a collective group when they “feel they have been subjected to a horrendous event that leaves indelible marks upon their group consciousness, marking their memories forever and changing their future identity in fundamental and irrevocable ways” (Alexander et. al., 2004, p.1). Genocide, such as the Holocaust, is an example of cultural trauma that disrupts cultural homeostasis, values, identity, and sense of belonging (Wolf, 2018).
The Diagnostic and Statistical Manual (DSM) 5 of the American Psychiatric Association (2013), places trauma and stress-related disorders in a separate section within the DSM. Exposure to different types of stressful events and whether individuals respond in adaptive or maladaptive ways usually determined whether a diagnosis is made. Post-traumatic stress disorder is defined as exposure to traumatic life event, intrusive thoughts and feelings associated with the event, avoidance relative to the event, worsening of mood following the event, hyper-vigilance, low self-esteem and impairment in functioning lasting for over 1 month (APA, 2013). Symptoms can arise right after the event or even months or years later (Talwar, 2007).
Art as a Vehicle for Resilience for Individuals Experiencing Trauma
Art Therapy and Trauma
Trauma often impacts nonverbal parts of the brain. Art therapy is what allows patients to tap into the primary processing of trauma in addition to the secondary processing available to them through talk therapy (Talwar, 2007). This allows for the processing and integration of traumatic memories and reduction in trauma symptoms (Schouten et al., 2015, p. 221). This helps people integrate their experience by connecting the left and right hemispheres of the brain as well as implicit and explicit memories. Much of trauma is encoded somatically through the autonomic nervous system of the brain. Research has shown that clients processing trauma experience bottom-up processing which starts at the bodily level and moves from sensation to perception, to cognition. Therefore, elements of “cognitive, emotional and affective memory” must be integrated and targeted through art therapy (Talwar, 2007, p. 25). Art can provide an integrating and symbolic way of processing trauma (Henderson, Rosen & Mascaro, 2007, p. 149). This allows for bilateral stimulation of the brain, similar to Eye Movement Desensitization and Reprocessing (EMDR) (Talwar, 2007).
Studies and testimonials suggesting the impact of art
The transformative aspect of art and its use as a vehicle for resilience has been suggested through generations. Friedl Dicker-Brandeis, an artist sent to the Terezin concentration camp during the Holocaust, found a way to teach art to children in the camp as a way to help children express themselves, find freedom within oppressive environment, and communicate their hopes and fears (Makarova, 2001). One of the children she taught later stated, “Everybody put us in boxes. [Dicker-Brandeis] took us out of them” (Makarova, 2001, p. 199). Dicker-Brandeis was able to hide and preserve 5000 pieces of art made by children in concentration camps with the help of her friend. These were found ten years after her death in the Auschwitz concentration camp (Makarova, 2001) and are displayed in a museum today.
Miriam Katin, a graphic artist, was a toddler during the Holocaust. She grew aware of her own “embodied experience of trauma” (Oostijk, 2018, p. 79); this awareness was reinforced after she learned about her mother’s recollections of this experience. Katin struggled with the aftermath of Holocaust long after fleeing from Nazi regime (Oostijk, 2018). She was able to utilize the creative process to reflect on her past, get a different perspective, reframe her experience, and “draw herself out of [the hurt]” (Oostijk, 2018, p. 84).
Although there are few studies on the impact of art therapy or art-making in general on resilience in Holocaust Survivors (HS), researchers studying this topic demonstrate the connection between creativity/inclination to art, and resiliency (Metz & Morrell, 2008; Diamond & Shira, 2018). Diamond and Shira’s (2018) study with groups of older adults, including Holocaust Survivors, suggests that engagement in art increases resilience and allows for “more positive coping with long-term effect of the Holocaust” (p. 241). Holocaust Survivors have reported higher symptoms of PTSD, depression, and anxiety compared to older adults who did not identify as Holocaust Survivors. However, in Diamond and Shira’s (2018) study, Holocaust Survivors engaging in art demonstrated greater resilience than both Holocaust Survivors who did not engage in art and the comparison groups of older adults (one group who engaged in art and another group who did not engage in art).
Revive Wellness Program
The Revive Wellness Program at Kleinlife, Philadelphia, was developed to address the unmet needs of Holocaust Survivors (HS) from the Former Soviet Union (FSU). Kleinlife’s (2017) mission includes emphasis on building community “among people of all ages and backgrounds, enhancing quality of life through social, educational, human service, and wellness programs.” The Revive program was funded through a grant from Jewish Federation of North America Center for Advancing Holocaust Survivor Care. Revive was meant to address the gap in services for HS from the FSU. Prior to the start of the program, FSU HS in the Philadelphia area lacked access to culturally sensitive, person-centered, trauma-informed holistic wellness services, that took into account their cultural background, language, and trauma history. In the beginning of our work together, our participants appeared to have complex unmet needs stemming from a history of complex/cultural trauma, living under an oppressive totalitarian regime, and their experience of acculturating to a new country as older adults. Because a series of complex, cultural traumas experienced by our participants impacted their wellness as a whole, it was essential for us to take a holistic approach to facilitate healing.
Program goals and structure
The Revive program aims to support participants in improving their physical, social, emotional, and spiritual wellbeing. All program staff are trained in Person Centered Trauma Informed (PCTI) Care. This model of care involves: 1) Participants being considered an expert of his/her/their own life experiences; 2) Participants getting to directly influence the services received; 3) Participants being involved in programming design and decisions; 4) Focus on personal strengths; 5) Practitioners being aware that each participant will bring a unique perspective; 6) Collaborative relationships with participants; 7) Transparency and trustworthiness; 8) Safety, choice, and empowerment; 9) Cultural humility; 10) Culturally appropriate approach that fosters rapport, trust, transparency, and collaboration; 11) Consideration of the psychosocial stages of development for our participants: meaning-making, life reflection, ego integrity, and the development of psycho-historical perspective (Newman & Newman, 2015).
New alternative methods needed to be incorporated into improving mental health that would better ensure that the FSU HS population did not experience the usual discomfort and stigma common in their culture when receiving traditional mental health services. Cultural sensitivity, encouragement of internal locus of control for program participants, and empathetic understanding/active listening were essential. Participants were involved in the development of program design, logo, and program name. Programming included culturally sensitive meals, tai chi, yoga/reiki, music and spirituality, individual meetings, subsidized trips/performances, larger cultural and holiday events, and creative arts therapies (dance movement therapy and art therapy).
Art Therapy in the Revive Program
Challenge of traditional art therapy
The presence of art (for most participants who do not consider themselves artists) and therapy in a culture where there is a huge emphasis on perfectionism (due to the discrimination many participants faced in many settings, including in educational institutions) and the stigma around mental health, initially led to hesitation from the program participants to engage in traditional art therapy. Because art therapy is not well known within the culture, it was necessary to not only destigmatize it, but also to differentiate it from an art class. An intersectional lens was essential to look at participants’ experiences and identities.
Expanding the scope of traditional art therapy practice was essential. Taking into account the PCTI approach, the participants’ psycho-social stage of development, receiving direct input from participants about their values, wishes, and needs, and building relationships with them through individual meetings, art therapy interventions were developed to meet participants’ needs.
Art Engagement #1: Family Album
In designing an art therapy intervention to introduce participants to this modality, opportunity for reflection, the ability to leave a legacy, the importance of family and continued desire to revive and learn were considered. It was described to them as follows: “Through the combination of art and technology, participants will learn how to develop a family album using their personal collection of photographs and images from the internet. They will receive a printed copy of a completed album free of charge to share with others. Art therapy may provide opportunity for positive self-expression, cognitive functioning, improved memory, emotional resilience, self-esteem, and socialization.”
Structure of family albums cycles
The creative process was described to participants. They were invited to gather their family photographs, meet with the facilitator and peers to receive support (both technical and emotional) in sorting through the photographs, as well as view a sample album. This allowed participants to organize their memories – through sorting and organizing photos as a way to reflect on, process, and make sense of their lives/create meaning. Photos were scanned for participants, with each one receiving a flash drive of them and their original photos back. Participants then met together weekly for 6-7 weeks in the computer lab to create a personal album using Shutterfly. During this time they were given an option to meet individually with the facilitator during the course of the project for both technical and emotional support. In many cases, emotional content came up and they were able to share their struggles in individual meetings and when comfortable in group settings. Safety and acceptance by peers and the therapist in navigating difficulties with technology led to greater acceptance of facing difficult memories. Once albums were completed, ordered, and received, participants gathered for two two-hour group sessions to share their albums, stories and feelings that came up for them (Keselman, 2019).
Unraveling the complexity of family series
The two examples below (of a married couple and the second case of an individual participant) demonstrate some common patterns that appeared across program participants. For the purposes of this article, to maintain the participants’ confidentiality, pseudonyms* were used. Both the couple and the individual participant entered the cycle with openness and positivity, and also the idea that “everything is great” and not wanting to “go there,” seeing “going there” as an indication of weakness. As they became more comfortable and reflected on their experiences, they appeared more open to sharing the more vulnerable parts of themselves.
Anna and Yosef*
Anna and Yosef, a HS FSU couple who have been married for 50 years, decided to work on one album together, merging their ancestry. Though Yosef allowed Anna to take the lead, both were invested in creating a story of their family, accurately representing their experiences of loss, joy, and life, and leaving a legacy for their children and grandchildren. Compared to other participants, they had greater exposure to technology prior to the start of the program. In working on the family album, they found themselves with some unanswered questions that led them to reach out to relatives all over the world to get some answers, allowing them to foster new and ongoing connections. Anna and Yosef involved their whole family, used creativity, and expressed commitment to leaving a memory for their children and grandchildren. They made attempts to piece together and make meaning of their disjointed family story due to family members lost during the Holocaust, and gaps in their family history. Anna included a black square to act as a visual representation of family members on her father’s side, who perished in the Holocaust (see Figure 1) – 72 people in the Jewish shtetl, her whole extended family. Yosef stated that the black square “says more than you can say with words; its impact stretched further than that point in time – it symbolizes everything that came after.” Yosef, too, did not know his father. Their hope was to prevent history from repeating itself by leaving a legacy, and sharing their memories with current and future generations. Meanwhile, they were coming to terms with the possibility that the work needed to put this puzzle back together may never be fully completed. In recording their roots, they were able to share valuable aspects of their identity and experiences with their family members. Leaving their mark was an act of defiance, healing, empowerment, survival, and revival.
Anna and Yosef discussed their recollection of hard times and happy memories – remembering the smallest details of their lives: “hard times and happy memories they are all good, they are all part of life.” Anna fondly recalled a moment when she used her wedding veil to sew a dress for her daughter for a holiday party in her daycare, due to not having the resources to purchase her one, which was a memory brought back by the photos used. Small details and more significant life events (i.e. losses, marriages, births) reminded participants about resilience and drive to survive. Identifying specific times when they were able to “get through it and making it work” acted as reminders of what they overcame, helping them deal with current stressors and challenges. Anna began meeting with the therapist individually to work through feelings that came up for her.
Sarah, a program participant who is naturally positive, expressed she was happy with the knowledge, insight, and support that she received during her participation in the art therapy cycle. However, Sarah ran into some difficulties along the way, both, with technology and painful memories. She joined the program cycle with little knowledge of technology. However, she exhibited great determination and was able to ask for support. Sarah was able to look at the bright side, and instead of focusing on challenges, she was focused on how “everyone was friendly and supportive and I knew I could always ask you for help.” She stated that “memories warmed my heart,” and now she had an “album left to stay for everyone.” Sarah frequently requested individual meetings to ask for technological support with the album, but also used the experience to talk about more personal and emotional content, something she never directly requested.
During her work on the project, she also had to cope with difficult memories; she expressed memories of childhood and the Holocaust, the anti-Semitism that she experienced as a student, happy times with her husband and coping with his loss, and immigration to the United States.
She shared that America opened new horizons for her. Despite setbacks (i.e. the transition “from being a professional doctor to a job as a babysitter”), she expressed gratitude for opportunities brought by immigration, and was reminded of her own resilience. She prepared an essay describing her experience with working on the album outlining what is shown on each page, using it as a way to maintain “memories of my life.”
When asking how Sarah was able to practice such a positive mindset even when faced with challenges during the cycle, she identified that “giving myself permission to feel all the feelings including challenging ones in turn helped me overcome them.” She identified knowing that she has overcome these challenges to help her “see all the feelings in a positive light.”
She also emphasized the importance of seeing the continuation of her family tree through her children and grandchildren, and identified happy memories to provide her with optimism. When asked for her permission to discuss her case in an article, with the assurance that her identity would be protected, Sarah reported that she was fine either way because she was proud of the work she has done. She reinforced the importance of staying active and participating in programs available through Revive to overcome current challenges.
Anna, Yosef, and Sarah’s experiences demonstrate some of the common themes that came up during this project, including the theme of resilience. During the process of creating a family album, the following themes emerged: all the participants were invested in creating a legacy for future generations and seeing the continuation of life in proceeding generations. Taking the time to gather and sort photos led to increased commitment throughout the duration of the cycle. They took this as an opportunity to acknowledge the impact of the past and to begin to heal from the pain through allowing themselves the opportunity to experience it, identify verbal and visual language for it, and receive support. Because many participants were children during the Holocaust, some experienced the impact of it prior to their language being fully developed. It was incredibly useful for them to process their trauma visually. Many participants required support in grieving the losses they may have never gotten the opportunity to address previously.
Through this experience came awareness and acknowledgment of the impact of the past on what followed and on current generations. Being able to express themselves through the visual medium and in their native language appeared helpful. It was easier for participants to request individual meetings asking for support in technology and letting the rest unravel than to acknowledge the need for emotional support due to the stigma within the community related to seeking mental health services. Realizing that they were not alone by getting feedback from peers within art therapy groups and other classes/sessions offered through the program allowed for increased openness. Still, some participants were comfortable sharing more than others, both in individual and group meetings. The therapist attempted to meet them where they were, and provided them with an accepting environment by adopting the PCTI approach. Some negative self-talk came up when struggling with technology, and participants had to be reminded that it was not an art or computer class, and they did not have to worry about being perfect. Although many uses of technology were new to them, they expressed their desire to learn it due to the increased prevalence of technology in their lives – free government phones, online applications, contact with family outside the country, etc. Reframing techniques were utilized during session and modeled for further use in other areas of their lives.
Resilience through art
The theme of resilience was evident for all the program participants. At the end of the project, program participants did not see themselves as victims of their challenges, but instead were able to focus on their strengths, what they had overcome, and the light and life that followed. Through the pain and trauma, they were able to see positivity and revival. Through art acting as a transitional object, they were able to reclaim their trauma narrative and story of life and survival. As a therapist, I was able to bear witness to the individuals’ trauma narrative in its original linguistic form. Acceptance allowed the program participants to let go of some of the need for perfection. Due to their desire to leave a legacy for future generations, many participants requested additional copies of the albums for their children. They brought albums to their other programs to share with peers, discuss their family story, and form connections.
Expanding the Coping Toolkit with Art Therapy
Once participants became more comfortable with the idea of art therapy and built relationships with peers and the therapist, they began demonstrating more openness to trying new things and became less worried about feeling judged. They demonstrated an increased desire to engage in activities previously unfamiliar to them for the purposes of healing and relaxation. Many participants from the family albums cycle, even those who demonstrated initial resistance and did not consider themselves artists, showed up. An “Art Therapy for Relaxation” series was developed to support participants in utilizing art and the creative process as coping tools for relaxation and stress reduction. Here, participants were provided with a variety of mediums and techniques within an accepting and safe environment, with additional support when needed.
Some logistical and clinical challenges continue to emerge due to the nature of grant-funded programs and doing work in a non-profit community setting. While every effort is made to provide participants with consistency, consistent scheduling and space continue to be a struggle. Additional challenges include the participants’ physical ability and limitations; potential difficulty in securing funding for continued meetings; limited capacity to provide individual meetings; the remaining stigma surrounding mental health concerns; and the need of our participants to ‘put on a happy face’ in order to avoid this stigma. Programs continue to be adjusted and revised based on participant feedback.
Throughout their lives, our participants, HS FSU, had to be resilient to not only survive, but to thrive and revive. This resilience appears to have been further accentuated and strengthened by the art therapy process. Through this process, they were able to create their trauma narrative in their language of origin and through imagery, offering a gain of autonomy over their own stories to further promote healing. The desire to be perfect is ingrained in them, and something that would take much longer to unlearn, but they have started on the process of letting go of this need. Accepting the imperfections and finding resilience, purpose, humor (i.e. laughing and joking about the imperfections in their art), and light became a part of healing. Due to the collectivist aspect of the culture, as some participants grew more comfortable, they invited their friends to join. Participants expressed feelings of pride and accomplishment.
Trauma lives in the body, and participants were able to use the experiences and imagery stored within their bodies to create a legacy. Openness and vulnerability allowed for stronger relationships and more support from peers and the therapist. This was essential as our participants come from a relational culture. Being reminded of the obstacles they have overcome, their own strengths in character, and learning coping skills to deal with current challenges, gave them the confidence to overcome current struggles. In this way, art has become a testament to their resilience.
Alexander, J., Eyerman, R., Giesen, B., Smeler, N., & Sztompka P. (2004). Toward a Theory of Cultural Trauma. Cultural Trauma and Collective Identity (pp. 1-30). Berkeley; Los Angeles; London: University of California Press. Retrieved from http://www.jstor.org/stable/10.1525/j.ctt1pp9nb.4
American Art Therapy Association. (2017) About American Art Therapy Association. Retrieved August 1, 2019, from https://arttherapy.org/about/
American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA
Cameron, J. (2005) The Sound of paper. Penguin Group. Hudson Street, New York.
Henderson, P., Rosen, D., & Mascaro, N. (2007). Empirical study on the healing nature of mandalas. Psychology of Aesthetics, Creativity, and the Arts, 1(3), 148-154. doi:10.1037/1931-38126.96.36.199
Keselman, M. (2019). Presentation on Creative Arts Interventions for Older Adults with a History of Trauma. Jewish Federation of North America Webinar, Philadelphia, PA
Kleinlife. (2017). History. Retrieved August 26, 2019, from https://kleinlife.org/about-us/history/
Makarova, E. (2001). Friedl Dicker-Brandeis. Tallfellow/Every Picture Press. Beverly Hills, CA
Newman, B. M., & Newman, P. R. (2015) Development through Life: A Psychosocial Approach, 12th ed. Belmont CA: Wadsworth Publishing. Philadelphia, PA
Oostdijk, D. (2018). Draw yourself out of it”: Miriam Katin’s graphic metamorphosis of trauma/ Journal of Modern Jewish Studies, 17(1), 79-92. doi: 10.1080/14725886.2017.1382103
Schouten, K. A., de Niet, G. J., Knipscheer, J. W., Kleber, R. J., & Hutschemaekers, G. J. M. (2015). The effectiveness of art therapy in the treatment of traumatized adults: A systematic review on art therapy and trauma. Trauma, Violence & Abuse, 16(2), 220-228. doi:10.1177/1524838014555032
Seth-Smith, F. (1997). Four views of the image. In K.Killick & J. Schaverian (Eds.). Art psychotherapy and psychosis. New York: Routledge. Pp. 84-105.
Substance Abuse and Mental Health Services Administration. (2019). Trauma-violence. Retrieved August 22, 2019, from https://www.samhsa.gov/trauma-violence
Talwar, S. (2007). Accessing traumatic memory through art making: An art therapy trauma protocol (ATTP). The Arts in Psychotherapy, 34(1), 22-35. doi:10.1016/j.aip.2006.09.001
Wadeson, H. (2010). Art psychotherapy. 2nd Edition. New York: John Wiley & Sons. Hoboken, New Jersey.
Wolf, D. (2018). Presentation on Cultural and Historical Trauma. Personal recollection of D. Wolf, Philadelphia, PA