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Therapeutic Use of Expressive Arts With Children
By Don Phelps, PhD, LCSW

In broken English, a 13-year-old boy asked if he could draw me a picture. I sat with him as he sketched a superhero he had seen on TV. The boy was very talented and drew with great detail and passion. When he finished, he smiled, gave the picture to me, and proudly said, “For you. Welcome!”

It was my first day volunteering at Casa Hogar Los Angelitos (CHLA) in Manzanillo, Mexico. The orphanage has more than 50 children and is registered as a Mexican civil association, which is a nonreligious, nonprofit organization. During the spring of 2011, I spent an extended period of time at CHLA as part of a university sabbatical. I asked to volunteer there because of its outstanding reputation for working with difficult-to-place children in Mexico. Most of the children come from toxic environments where they experienced domestic violence, homelessness, physical and/or sexual abuse, prostitution, sexual assault, neglect, and/or abandonment.

During my professional career as a social worker, I have been privileged to visit many orphanages around the world. Most of them provide the basic survival needs of children, including healthcare, clothing, food, and shelter. The children survive but few thrive. They often repeat the patterns and lifestyles of the poor and abusive homes they grew up in. Because of the lack of resources, few orphanages effectively address the complex needs of traumatized children.

A Success Story
I started my sabbatical experience at CHLA with the following questions: Why is CHLA so effective with difficult-to-place children given its limited resources? Why are CHLA children more likely to remain in school and go to college? Why are the organization’s rates of teen pregnancies, drug use, gang involvement, and criminality so low?

I discovered many reasons for CHLA’s success while I was there. The organization has dedicated staff, passionate volunteers, visionary leadership, and a holistic approach to child development. A surprising finding, and perhaps a major reason for CHLA’s success, is the extensive daily use of expressive arts with the children.

Children receive music instruction and have regular access to instruments. They can train and participate in a skilled and prestigious dance troupe that performs traditional Mexican dances locally, nationally, and internationally. Children have access to donated art supplies and regularly draw and paint. Many participate in creative writing, journaling, and poetry.

Expressive arts are integrated into each stage of the children’s development. Through a wide variety of programs, CHLA facilitates emotional and creative expression, helps heal psychological wounds, and accelerates developmental growth through its use of the arts. I have never seen an orphanage embrace the arts as fervently.

Therapeutic Value of Expressive Arts
Art is an important and universal facet of human expression and is as old as human civilization. “The use of art for healing and mastery is at least as old as the drawings on the walls of caves” (Aron-Rubin, 2005, p. 6). Expressive arts include activities such as dancing, drawing, drama, creative writing, painting, writing poetry, making music, sculpting, and photography.

Professions such as art, music, and movement therapies require graduate-level training and special professional certifications in the United States. The therapeutic use of expressive arts by noncredentialed professionals and paraprofessionals in orphanages is different in that it simply focuses on the inherent therapeutic value of children participating in creative endeavors. Both approaches encourage creative expression, but the context, facilitation, and purposes are different. Most orphanages would welcome the opportunity to have expressive art therapists but the lack of funding and the availability of these specialized professionals in developing countries usually limit their use. Instead, orphanages such as CHLA use expressive arts as a way to supplement the care that children receive. Most of these activities are facilitated by volunteers, clinical staff, or childcare workers.

Creative arts allow children the opportunity to grow and develop self-awareness through self-expression. This has been shown to reduce stress and accelerate psychological and physical healing. For many children and adults imprisoned in German concentration camps during World War II, drawings and paintings were used to cope with the horrors they saw each day. Prisoners had to carefully hide their work, as many were killed when their art was found (Orstein, 2006). They traded food for painting supplies and used garbage, old boxes, and newspapers to paint on. Paint was made from coal soaked in water, watered-down rust, and vegetable dyes. “They responded to an imperative psychological demand to put on paper what they saw and what they felt” (p. 395-396). Painting and poetry were a way for them to survive and cope.

I began to use expressive arts as a young counselor in the 1980s out of pure desperation. I worked with adolescents who struggled with mental health and substance abuse problems. Traditional talk therapies did not seem to work very well. I started reflecting on my own adolescence and the activities that helped me cope with stress and family problems. Activities such as making music, sports, writing poetry, and outdoor adventure provided outlets for expressing myself and helped me manage stress and adolescent angst.

Much to the dismay of many of my coworkers, who tightly subscribed to traditional approaches, I started incorporating expressive arts into my counseling sessions. As my successful outcomes with adolescents increased so did the agency’s support of my methods, including the use of licensed and certified art therapists, music therapists, dance therapists, outdoor adventure therapists, and exercise physiologists in our residential treatment programs. These programs supplemented traditional individual, group, and family interventions. The organization found that successful treatment outcomes were higher for adolescents who participated in expressive therapies than those who did not.

Trauma Work Through Expressive Arts
Most of the children at CHLA have a history of trauma, and several display symptoms of posttraumatic stress disorder (PTSD). For some, attachment bonds with primary caregivers were absent, disrupted, or severed at an early age. This destroyed the trust and security essential for healthy emotional growth and relational intimacy, since early relationships provide the emotional, neurological, and social foundations for our ability to love (Perry, 2009).

During my stay at CHLA, I heard heartbreaking stories of domestic violence, physical torture, sexual abuse and assault, drug addiction, prostitution, extreme neglect, and abandonment. Past traumatic events are difficult for children to talk about. They have not yet learned the words to describe the internal sensations, memories, images, and snapshots. The children frequently repress painful emotions and horrific experiences as a basic survival mechanism (van der Kolk, 2002). Children with a history of trauma experience multiple losses and carry the toxic memories from their past. They have a higher risk of experiencing mental health problems as adults. The dissociative behavior and posttraumatic stress experienced as a result of abuse and neglect negatively impacts a child’s ability live a healthy, satisfying life. Alice Miller (1984) wrote,

The truth about our childhood is stored up in our body and although we can repress it, we can never alter it. Our intellect can be deceived, our feelings manipulated, our perceptions confused, and our body tricked with medication. But someday the body will present its bill, for it is as incorruptible as a child who, still whole in spirit, will accept no compromises or excuses, and it will not stop tormenting us until we stop evading the truth. (p. 315)

Expressive arts have long been used with children to promote psychological health and social support. They offer children “a way to express their feelings, perceptions, thoughts, and memories in ways that words cannot” (Malchiodi, 2005, p. 9). Studies indicate that expressive arts assist healing from childhood trauma and aid in overall mental health “by providing opportunities to share experiences in an empathic environment through symbolically expressing emotions in a concrete way” (Smilen, 2009, p. 381). The staff and volunteers at CHLA engaged and positively reinforced children in the creative process by providing a safe space for them to express themselves. Because most children enjoy drawing, painting, singing, and dancing, art is a simple way for children to learn multiple forms of expressions. Children are allowed to express themselves without judgment or criticism. They are given the ability to choose from various creative activities that increase their sense of internal control and willingness to participate.

Supportive peers can also be a great asset in the creative process. Many expressive art activities at CHLA are done in small groups. This cultivates social interaction, mutual support, peer modeling, and empathy development (Cumming & Visser, 2009). Completing a work of art or finishing a performance in the presence of supportive peers and adults can raise a child’s confidence and self-worth. By creating and sharing in a safe and supportive group, children are able to break their sense of isolation and shame. They discover symbols, labels, and other forms of expression that accurately reflect their own inner landscapes. Bhagwan (2009) wrote, “Individuals do not exist as isolated, discrete or separate entities, but as interconnected beings whose growth, well-being and transformation are shaped by dynamic and fluid relationships between friends, family, the global community, and a Higher Spirit within the Universe” (p. 226).

At CHLA, I frequently observed older children teaching younger children how to dance, play the guitar, or paint. I would hear comments from peers of children sharing drawings and poetry, such as “This one looks really sad” or “This one sounds angry.” They would ask each other questions about their art, give encouragement, and comfort one other if the process brought up past issues or difficult emotions. Adult facilitators carefully monitored this process and offered affirmation and validation.

Expressive Arts Help Heal
Expressive arts assist in the healing process by altering a child’s physiology. When children engage in expressive arts, it alerts the parasympathetic system in their brain (Lane, 2005). Their breathing slows, their blood pressure lowers, and the body becomes more relaxed. This helps reduce the physiological hyperarousal, or fight-or-flight response, associated with stress. Creative expression modifies our biochemistry and improves our physical well-being. When children participate in the arts, it actually changes their bodies.

The creative process causes specific areas of the brain to release endorphins and other neurotransmitters that affect brain cells and the cells of the immune system, relieving pain and triggering the immune system to function more efficiently. Endorphins are like opiates, creating an experience of expansion, connection, and relaxation. In conjunction with these physiologic changes, art can regularly change people’s attitudes, emotional states, and perception of pain. (Lane, p. 122)

Neurophysiologists have shown that “art, meditation, and healing all come from the same source in the body; they are all associated with similar brainwave patterns and mind-body changes” (Lane, p. 123). A child’s age and stage of development “has a profound impact on how an educational, care-giving, or therapeutic experience will influence the brain” (Perry, 2009, p. 243). Children who are traumatized when they are very young will respond and cope differently than children who are traumatized as adolescents.

Because of the way the brain develops, from the bottom up and from the inside out, different areas of the brain are impacted during trauma depending on the age of the child. The younger a child is during the trauma, the more necessary it is to stimulate specific neuropathways that promote healthy brain development (Perry). Certain neuropathways in the brain are developed and others are underdeveloped depending on the experiences of the child.

This is a significant problem in the conventional mental health approach to maltreated children; many of their problems are related to disorganized or poorly regulated networks (e.g., the monoamines) originating lower in the brain. Yet, our clinical interventions often provide experiences that primarily target the innervated cortical or limbic (i.e., cognitive and relational interactions) regions in the brain and not the innervating source of the dysregulation (lower stress-response networks). Even when targeting the appropriate systems in the brain, we rarely provide the repetitions necessary to modify organized neural networks; 1 hour of therapy a week is insufficient to alter the accumulated impact of years of chaos, threat, loss, and humiliation. Inadequate ‘‘targeting’’ of our therapeutic activities to brain areas that are not the source of the symptoms and insufficient ‘‘repetitions’’ combine to make conventional mental health services for maltreated children ineffective. (Perry, p. 244)

Trauma is often kept in one’s memory as sensations, symbols, and mental images that can be difficult to access in traditional talk therapy or informal conversation. These memories are situated in the primitive sections of the brain and may not be part of a person’s conscious awareness. Expressive arts help children manage experiences that are too difficult or painful to assimilate. In his research on child trauma, Perry found that activities such as dance, massage, music, yoga, drumming, and other similar interventions provide the patterned and repetitive neural input to alter the lower stress-response networks of the brain and help children better cope with the symptoms related to their trauma. This could explain the many benefits children at CHLA receive from participating in the dance troupe. They practice their traditional Mexican dances many times per week. Their performance shoes have taps on them that make a percussive sound when they dance. While they rehearsed, I often closed my eyes and listened to the rhythms being created. The children emphasized specific beats and memorized the dance by the rhythmic sounds being created.

A child’s spiritual awareness and development can be improved by the use of expressive arts. The use of dance deepens “children’s spiritual awareness and provides a context for the development of a kinesthetic intelligence, which allows children to embody and give expression to abstract concepts and ideas” (Bhagwan, 2009, p. 229). Creative arts also “engage children in learning that is intimately related to spiritual development, involving self-understanding, understanding relationships, wider environmental connectedness, and connection with the divine” (Coholic, Lougheed, & Lebreton, 2009, p. 31). The arts engage the senses in a way that transcends the ordinary and mundane aspects of life. As children connect to their poems, songs, dances, or paintings, they become more aware of their thoughts, emotions, and core beliefs. This assists in self-discovery and self-understanding and helps them find meaning.

During my sabbatical, I observed children at CHLA make great strides in their development and healing by participating in expressive arts. They beamed with pride and confidence after a dance or musical performance. Paintings and drawings were used to communicate a wide range of emotions and experiences. It was as if the arts were a normal and regular means of expression for the children there. The use of the creative process in each child’s life was planned, organized, and well facilitated, and the results were impressive and inspiring. The dedicated staff and volunteers have been able to reach and engage hundreds of maltreated children through the natural restoration and rejuvenation that occurs when we engage in expressive arts.

Given the limited access to psychological resources in such settings, childcare workers must be strategic in their methods and strategies. Expressive arts are a relatively inexpensive and effective method to engage child who have experienced trauma. It is surprising that more orphanages have not incorporated them into their program.

CHLA uses expressive arts in a way that is fun, therapeutic, and inspirational. Creativity and imagination serve as a catalyst in the children’s emotional, social, physical, and spiritual growth. Further trainings must be provided for childcare staff and volunteers on ways to use expressive arts without practicing beyond their level of competence. Experts in art, music, and movement therapies could create inexpensive and safe activities to use with some guidance on how to facilitate the process. Further research is needed in the use of the arts in orphanages throughout the world, as there are many variables involved in determining what makes an orphanage successful in working with traumatized children.

If these talented children are to thrive and blossom to their full potential, we must be open to all innovative, inexpensive, and evidenced-based approaches that help them heal from trauma.

— Don Phelps, PhD, LCSW, is an associate professor in the School of Social Work at Aurora University in Illinois. Over the last 25 years, he has worked as a youth and family therapist, clinical director, chief operating officer, and CEO.

References
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Bhagwan, R. (2009). Creating sacred experiences for children as pathways to healing, growth and transformation. International Journal of Children’s Spirituality, 14(3), 225-234.

Coholic, D., Lougheed, S., & Lebreton, J. (2009). The helpfulness of holistic arts-based group work with children living in foster care. Social Work With Groups: A Journal of Community and Clinical Practice, 32(1-2), 29-46.

Cumming, S., & Visser, J. (2009). Using art with vulnerable children. Support for Learning, 24(4), 151-158.

Lane, M. (2005). Creativity and spirituality in nursing: implementing art in healing. Holistic Nursing Practice, 19(3), 122-125.

Malchiodi, C. (2005). Using art activities to support trauma recovery in children. Trauma & Loss: Research & Interventions, 5(1), 8-11.

Miller, A. (1984). Thou shalt not be aware: Society’s betrayal of the child. New York: Farrar, Straus and Giroux Publishing.

Mountain, V. (2007). Educational contexts for the development of children’s spirituality: exploring the use of imagination. International Journal of Children’s Spirituality, 12(2), 191-205.

Ornstein, A. (2006). Artistic creativity and the healing process. Psychoanalytic Inquiry, 26(3), 386-406.

Perry, B. (2009). Examining child maltreatment through a neurodevelopmental lens: clinical applications of the neurosequential model of therapeutics. Journal of Loss & Trauma, 14(4), 240-255.

Smilan, C. (2009). Building resiliency to childhood trauma through arts-based learning. Childhood Education, 85(6), 380.

van der Kolk, B. A. (2002). In terror’s grip: Healing the ravages of trauma. Cerebrum, 4, 34-50.