Creative Arts Therapies in SUD Recovery — Expressing Emotions Beyond Words
By Sue Coyle, MSW
Social Work Today
Vol. 20 No. 4 P. 16

Practitioners use creative and expressive therapies to help clients struggling with substance use disorders cope with feelings that have eluded verbal expression.

“I’m not an artist.”

Kirsten Tincher, an art therapist at the Oxford Treatment Center in Oxford, MS, often hears these words, or a variation thereof, when new clients enter her group space. They are, in fact, thoughts she echoed as a student. “I grew up hating art,” she says. “I grew up believing that I was terrible at art.”

It wasn’t until Tincher got to college and started to learn about art therapy that “I found that there is no good and bad. It’s expression. It’s a way to conceptualize. Art is a way to process and heal and grow,” she explains.

Tincher uses art in group and individual sessions to help the residents, all of whom are addressing substance use disorders (SUDs), communicate and open up not only to her but to the group and to themselves as well.

The use of art therapy in such a setting is not unusual. In fact, practitioners focusing on SUDs throughout the country use creative and expressive modalities regularly.

Creative/Expressive Therapies
Creative arts therapy can take many forms. Perhaps the most commonly thought of form is visual art therapy, but even that can be offered in a variety of different ways. It is not defined by a single type of creating.

Lauren Zeltzer, MIA, ATR-BC, LCAT, a clinician at a major New York City hospital’s SUD outpatient clinic, describes art therapy as “an experiential therapy that engages different parts of our brain than verbal therapy alone. Art therapy is a safe, effective way to express and process feelings that can be obscured in talk therapy, mirroring our feelings and experiences at a deep level while at the same time stimulating new ways of seeing, feeling, and thinking, leading to heightened insight and self-awareness, innovation, self-esteem, empowerment, and change.”

Art therapy may involve painting, collage, using crayons, or—one of Tincher’s favorites—making mandalas as a mindfulness exercise.

In addition to visual arts, creative arts therapy may take the form of music therapy or drama therapy.

Psychodrama experiential therapy is used at Sierra Tucson in Arizona, for example. In those groups, clients are offered the opportunity to role-play, involving other group members both as actors and observers. Camille Drachman, MSW, LCSW, SEP, associate director for the trauma healing program and director of new program development at Sierra Tucson, says that when the practitioner creates a safe, open space, everyone—from the lead role-player to the observers—is able to learn during a psychodrama group. But it is challenging.

“It can be deeper work, and it can bring up a lot of difficult feelings and memories. It can be scary,” she says. “A skilled [practitioner] is going to be able to set up group so that it is a safe container.”

Sally Bailey, MFA, MSW, RDT/BCT, a professor and director of the drama therapy program at Kansas State University, adds, “Drama is all about connection, communication, and understanding emotions, which are all skills people with SUD are in need of developing. It’s also very based in the here and now. So it makes clients feel alive again!”

Outside of and including the more commonly thought of creative arts is expressive arts. This form of therapy is more wide reaching than some of the aforementioned modalities. “We are looking at how the arts can be woven together,” says Danielle Drake, PhD, an associate professor and program cochair of the expressive arts therapy program at the California Institute of Integral Studies. “We don’t just focus in on one particular art. We might be doing something related to movement and then transition onto something related to writing. We are mixing all of the different modalities.”

Regardless of which modality is employed, the point of creative and expressive therapies is to allow the individual and/or the group to explore new ways of learning about themselves and their healing process—through their senses, their actions, their bodies, and their spirits.

Treating SUD
These types of therapies could be applied to individuals in a variety of populations and settings. However, they seem particularly effective when working with individuals with SUD for a number of reasons.

To start, SUDs and the individuals struggling with them are complex. Use is not the only problem faced and thus cannot be the only issue addressed.

“The older paradigm is you just stop using,” Drachman says. “You do the next right thing, and everything is okay. But under every substance user is a bevy of issues such as trauma or mood disorders. It’s never just substance use.” Thus, treatment must be holistic in nature, including talk therapy as well as a variety of other modalities that allow the individual to work toward recovery.

Expressive arts therapy fits the bill, Drake says, because of its ability to help slow down the individual—their body and their mind. “When people engage in substances and when it’s gone from use to abuse, the body and brain are often negatively impacted,” she says. Individuals with SUD often stop being able to make positive choices for themselves, become accustomed to immediate gratification and tend to have chaotic, disorganized thinking.

“All of that leads to putting themselves in dangerous situations that can lead to trauma. What the arts can do is help slow the body down, slow the thinking down, help people engage more frequently in delayed gratification, allowing them to become more linear and thoughtful in their processes and narratives,” Drake says.

Once slowed, individuals are better able to create and express themselves. They have the opportunity to explore more challenging emotions and experiences, perhaps communicating something through art that they felt unable to say with words.

But—and this is key—they don’t have to do it all at once. Creative art therapies allow for individuals to take small steps forward until they are ready for larger ones. Take for example drama therapy. “It allows them to be embodied and feel emotions in small, pleasant doses, which develops deep trust. And then they can begin to take risks and get closer to working on the painful stuff later on,” Bailey says.

“And it’s always okay to make a mistake in drama, because then you can play out the situation another way and use the mistake as a teachable moment without shaming anyone,” she adds.

And as an added bonus, it can be fun. “Creativity is fun and life affirming,” Zeltzer says, “which is a powerful antidote to shame and low self-esteem, common precursors/effects of SUD. Patterns of perfectionism, needing to control, fear of exposure, and negative messages from our family of origin often surface when engaging with art materials, providing an opportunity to challenge them directly and work through them with compassion, humor, and respect.”

Challenges
While creative art therapies seem highly conducive to working with individuals with SUD, the implementation is not without its challenges.

There can be resistance to doing something creative. Many think of therapy as a one-on-one session with a therapist or a group conversation. The concept of painting or singing may be both a surprise and off-putting. It also is a request for vulnerability, not only because the creative act may reveal a challenging emotion but also because people prefer activities they are a good at and comfortable with.

“Be prepared for resistance,” Tincher says “No matter what you do, there are going to be patients that have either had difficult situations with art or been embarrassed about their art. It’s not you that they’re resisting.”

David Cato, LCSW, TCT, SEP, associate clinical director at Sierra Tucson, says just get them to try.

“When I work with residents, I tell them, just try it one time. Sometimes they would try it and say, ‘That’s not really a modality for me.’ Everyone is different. If something doesn’t land, there’s bound to be something that does,” he notes. Sierra Tucson offers a wide array of therapies from psychodrama to equine-assisted therapy to somatic experiencing.

Even if someone tries, however, there can remain a fear of judgment. It is the practitioner’s responsibility to allay that fear. Zeltzer says that an art therapist can do so by focusing on the client’s interpretation of their work. “While art therapy master’s programs include training in symbolism and metaphor, assessment procedures, psychopathology, and diagnosis, a crucial aspect of sound practice is incorporating clients’ own discussion of their art work and process, including personal meanings of symbols and subject matter.”

Relapse can also be a challenge. According to the National Institute on Drug Abuse, between 40% and 60% of individuals with SUD will relapse after entering recovery. Relapse is even often included in the Stages of Change model as the stage after maintenance, leading back to precontemplation.

When using creative arts therapy, the approach to relapse will depend on the substance, Drake says. “Different substances require different approaches. The hardest one to work with is meth. The level of dopamine that it pumps into your body is 100 times more than cocaine. People are looking for an immediate feel-good sensation, and that’s what they get.

“There’s not really a way to navigate that except to be in it and slow it down. Slow things down into micromoments. Notice the breath; count the number of objects on the wall. Bring that emotional regulation down to a point that’s manageable and find lots of creative ways to distract,” she says by way of example.

Tools
With resistance and relapse being only two of the possible challenges creative art therapists face in working with this population, it is important that they have the tools they need to be effective.

One such tool, Cato says, is experience. He encourages therapists interested in learning about a new modality to take a few sessions within that modality themselves. “It can be difficult to sign up for something. That first module or group that you go to might feel a little weird. [But] reach out to someone. If you hear about a service, reach out and see if you can connect with someone. There are a lot of practitioners providing different types of therapy,” he encourages.

Once a therapist has experienced a modality, they will know whether it is something they want to pursue with proper training and certification. And when they eventually become the ones delivering the therapy, they will be able to do so knowing “this works.”

In a similar vein, Tincher encourages modeling. “I see better results when I can show an example. They are looking for that foundation. It’s not showing a Van Gogh. Create something yourself or have artwork from past clients.”

And when modeling or offering examples, don’t hold back. Do create appropriate boundaries and maintain the professional relationship, but don’t be afraid to create and express. Be silly, Bailey and Drake say.

“Many people who want to do arts intervention are not willing to be silly,” Drake says. “Unless you are going to let go of that for a little bit, your interventions are not going to work.”

Bailey agrees. “They will only participate at the same level that you are participating, and if you are willing to throw yourself into warm-up games, they’ll follow suit.

However, she adds, there must be a balance of fun and seriousness. “Early on, clients catch on that what you are doing is exploring new options through action and through metaphor. So while it’s fun, there’s a lot of depth underneath what you are doing. After all, drama therapy is the intentional use of drama.”

COVID-19
These tools are even more important now as facilities, practitioners, and clients have struggled with the impacts of COVID-19. As stay-at-home orders were implemented throughout the country, much attention was given to the likelihood that the isolation would be challenging for individuals in recovery.

At residential facilities such as Sierra Tucson and the Oxford Treatment Center, many were unable to discharge home. The travel it would have involved was deemed unwise and/or flights were canceled.

At Sierra Tucson, services were adjusted to allow for smaller, more socially distant groups.

And while intakes and ongoing therapy continued, Tincher says that residents seemed a little more anxious. Her approach was to address concerns so that she could bring the focus back to her planned topic. “I don’t want to just dismiss it,” she says.

For those at home during COVID-19 living with SUD, Drake advises a similar plan of action. “You can’t just hop to the gratitude. You’ve got to give space for the angst. I will encourage my clients to write what it is that they’re feeling. You just want to curse, write it down. Tag it on the page. But then don’t stay there.”

She encourages her clients to devise a schedule infused with creativity. “I am a proponent of creative living,” she says, noting that it exists in so much of what people naturally do each day. “If you are making your breakfast, that is a creative act. Brushing your hair and styling it is a creative act. Notice the moments of creativity that you naturally do and ways to expand on it. I think everyone should have paper, pen, pencils, and markers at home. Everyone needs it, because we have to take care of the little kid inside of us.”

The use of creative arts and creative arts therapy through the pandemic may help some prevent or begin to recover from relapse. And, that points to another reason why creative arts therapies and SUDs pair well.

Learning how to use creative expression is a lifelong tool, just as recovery is often a lifelong process.

— Sue Coyle, MSW, is a freelance writer and social worker in the Philadelphia suburbs.