Meijer-Degen

Art therapy for mental health workers

in areas affected by violence: a rarely
explored resource
Fiety Meijer-Degen

Experiences with survivors of extreme violence of cultural backgrounds who have experi-
demonstrate that treatments that focus exclusively enced traumatic events (Gilroy, 2006;
on verbal expression are often insu⁄cient. Howie, Prasad & Kristel, 2013; Malchiodi,
Furthermore, evidence has shown that art therapy, 2008; 2012; Goodman, 2009).
as an initially non-verbal therapy, has an important Art therapy is de¢ned as a form of
role to play in the treatment of people from a wide psychotherapy in which verbal expression
variety of cultural backgrounds. However, most of is either replaced, or supported, by other
the evidence gathered to date is through work means of (art based) communication,
with refugees in the West. Therefore, this ¢eld such as: painting, drawing or working with
report adds to the body ofevidence through describing materials (e.g. clay, etc.). In art therapy, a
the application of art therapy, in daily practice, in creative process that easily evokes a set of
areas a¡ected by violence.The author, an art thera- emotions precedes talking about experience.
pist from the Netherlands, has done trainings in Compared to other forms of psychotherapy,
art therapy, with trainees of over 35 nationalities what is created in art therapy is visible,
and in 15 di¡erent post con£ict areas. Participants tangible and can be preserved for later
were primarily unfamiliar with art therapy and are examination. The therapeutic environ-
mental health workers.The author reports that use of ments, where these creations are made, are
art therapy techniques often resulted in surprising often playful and personal. However, the
and stimulating e¡ects on the level of commitment, most essential feature of this therapeutic
and the development of insight, of the trainees. form is that clients who make the object
initially may not realise the signi¢cance of
Keywords: areas a¡ected by violence, it. Clients may deny the (devastating and
art therapy, psycho trauma, psychosocial, painful) stories that their creations contain,
training, unexplored potential until they ‘feel up to the confrontation’. As a
result, this form of treatment is particularly
useful in providing assistance to children
Introduction: art therapy and adults who are unable to verbally
Experience with survivors of concentration express experienced events. Additionally,
camps in World War II, and of the many those that may have the words, yet suppress
wars that have followed since, demonstrates the verbal expression of their emotions, can
that treatments that focus exclusively on also bene¢t from this therapy. Importantly,
verbal expression are often insu⁄cient, as no speci¢c or artistic abilities are required
some survivors may be unable to articulate to bene¢t.
experienced events. At the same time, Depending on the nature of the problems
more and more evidence has emerged that experienced, and the possibilities of the
art therapy ^ as an initially non-verbal participant, art therapy treatment can lead
treatment ^ has an important therapeutic to increased awareness, change, acceptance
role to play with people from a wide variety and increased ability to cope. Exercises can

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 Art therapy for mental health workers in areas affected by violence: a rarely explored resource
Intervention 2014, Volume 12, Number 1, Page 99 - 107

focus on the past, the present, or the future.  Speci¢c appeal: Each material makes its
The objects or images can also be helpful own speci¢c appeal to a variety of motor
for the therapist to understand the nature of and emotional responses, and o¡ers the
the problem, the current circumstances of opportunity to experiment and play. For
the patient, and/or the client’s own potential example: ¢nger paint encourages smear-
solutions. Art therapy is also useful when ing or clay encourages kneading, etc.
working with people from di¡erent cultural  Direct experience: The person enters a
backgrounds and languages, providing both situation where they actively experience
a method to connect with clients, and to open the smell and colour of the paint, the
possibilities for change. Also, these methods sound of the pencil on paper, and witness
can be applied individually, or in groups. and participate in the emergence of
While there are various publications about an entirely personal creation. Only after-
the use of art therapy in traumatised wards does re£ection take place on what
refugees in the West (e.g. Wertheim-Cahen has happened and been created.
et al., 2004), little has been written about  Diminished conscious control: Often a
the use of art therapy in post con£ict situation of trance occurs, in which
countries.1 Therefore, this ¢eld report aims unexpected or even unwanted images
to contribute to documented experience arise. The control, or censure, that one
through sharing insights developed during tends to impose is lost or overcome.
several training missions in con£ict a¡ected  Creation: A creation occurs that is
areas. The author has implemented the tangible, visible and (mostly) durable.
training missions over the course of many This creation is a lasting symbol of the
years, in more than 15 countries, with experience gained at that moment, and
participants of over 35 di¡erent nationalities. as such it can also have a function after
that moment. One can distance oneself
from it, be surprised by it, rejoice in it,
Why use art therapy in post or get excited by it.
con£ict settings?  Absence of a linear character: There is no
In many cultures, it is uncommon or inevitable beginning nor end, as is the
generally unaccepted to openly communi- case in a verbal story. Many things can
cate emotions, desires or painful experi- be seen simultaneously, side by side, at
ences. Art therapy therefore, has the great one glance. In this way, new connections
advantage of circumventing such limita- can be made: past and present, unity
tions, as well as overcoming accompanying and division, far and near. They can all
emotional barriers. Unfortunately, while come together in one piece of work.
art therapy can bring great value to psycho-  Disclosing wordlessly stored experiences:
social and mental health work with people Within the memory of some experiences,
who have experienced collective violence, only fragments exist: an image, a smell,
it remains a largely under-utilised and often or the memory of an emotion. This does
ignored resource. Art therapy is a resource not only apply to memories from the time
that, in the author’s experience, has several when our ability to verbalise and under-
aspects that set it apart from other forms stand language had not yet developed,
of therapy, including: but it also applies to overwhelming
events that have initiated a primal level
 Taking control: Art therapy o¡ers an of response, such as experiences with
opportunity to be active and to use violence, abuse, natural disasters, etc.
one’s own capacities and creativity (Based on: Meijer^Degen & Lansen,
(empowerment). 2006)

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 Meijer-Degen

Art therapy training within post against a backdrop where a portion of the
con£ict settings population had been severely traumatised.
Before training within post con£ict zones, A related problem, frequently encountered,
the author had worked for years in the was that most trainees also form part of
Netherlands, the United States and South this population, and have often survived
Americaasanarttherapistwithparticipants damaging experiences themselves. They
from a wide diversity of cultural back- tend to be exposed to the same di⁄culties
grounds that had experienced violence, as the people they want to support.
and as a teacher in advanced training in art Additionally, an initial aversion to art
therapy. These experiences proved to be therapy surfaced sometimes, especially
very valuable. with highly educated trainees and trainees
They were not, however, enough preparation that were ‘high-ranking’ within existing
for the additional challenges of working in hierarchies. As they too were unacquainted
post con£ict settings, where the logistics of with art therapy, they asked for literature
being within the location were often intrinsi- and theory at the start of the training.
cally demanding and di⁄cult. Not only in Trainees are usually hesitant to apply the
terms of the di¡erent needs of the local unknown. However, the author’s approach
population, but also the constant threat, is based on learning by doing and experien-
the destruction, the demoralisation of the cing. Only later in a training are theoretical
trainees and the awareness of running risks aspects gradually introduced.
myself, all contributed to making it di⁄cult.2
Another challenge was that in most Developing training
countries where support was requested, In general, the objective of art therapy
there was no speci¢c demand for art therapy. training is to provide the trainees with the
Often, local organisations had asked for pro- ability to apply art therapeutic interventions
fessional development programmes and/or in their assistance to traumatised people,
improvement of existing methods of the through:
treatment of psycho trauma, among others.
What form and content these programmes  deepening of self-knowledge;
or improvements should take was often  expanding professional attitude;
unclear. For most aid workers in areas with  increasing theoretical knowledge;
collective violence, art therapy is unknown.  increase of therapeutic skills;
They have no idea what to expect and are  learning to establish an e¡ective
mostly ambivalent about this approach. therapeutic relationship; and
For example, prior to art therapy training in  learning how to work with simple art
Nepal, experienced psychosocial trainers materials.
warned me that such training would most
likely fail. In fact, the opposite happened, the Time available is also often a decisive factor
arrival of a new group of trainees after the when setting training objectives.These objec-
¢rst week of training led to protest by the ¢rst tives may vary fromenabling traineestoapply
group of trainees, as they wanted to continue. basic therapeutic interventions to enabling
The author worked with trainees from them to work out treatment plans and to
various educational backgrounds: from convey the application of art therapeutic
professional (aid) workers to teachers, and interventions to colleagues, through cascade
from artists to psychology students. Some training. It is not, however, the intention to
trainees had a high level of education, but train the trainees to become art therapists.
most had only had short courses in psycho- The emphasis is rather on experiential
social counselling. These trainings occurred learning or ‘doing before talking’. The trainees

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 Art therapy for mental health workers in areas affected by violence: a rarely explored resource
Intervention 2014, Volume 12, Number 1, Page 99 - 107

experience a lot of pleasure in being active own creations and to look at an artwork
themselves and often enjoy working with as a resource where many meanings
visual materials and games. They appreciate are visible. Trainees have to learn through
they do not have to listen passively to asking open questions about the artwork
an expert and often enthusiastically share of others, and to stimulate the creator to
what they have experienced during the ‘open up’ and share their experiences while
creation of an object or image, and what creating the artwork and about the art-
the end results mean to them. work itself.
Through a series of exercises that appeal
to the imagination of the trainees and Opportunities during training
evoke di¡erent, sometimes strong, emotions, Training in art therapy has some particular
the trainees observe and experience (in features that may be used as opportunities.
themselves and other participants) that their
clients may go through when exposed to 1. Focusing on emotions of trainees
an art therapeutic approach. During the Art therapy focuses on the individual
¢rst phases of the training they learn emotional experience of the trainees
about the speci¢c qualities of di¡erent themselves.When the trainees are unable
materials, and how and when to introduce to recognise their own feelings, it is not
them. Later on, theoretical issues on art likely that they can help their patients
therapy, psycho trauma and psychiatry are e¡ectively with the reliving and integrat-
introduced. Gradually, the focus shifts from ing traumatic experience.Training in art
sharing personal reactions to discussing and therapy creates a climate that facilitates
practising possible applications in real life, the exchange of these private, emotional
therapeutic situations. Over the course of experiences. Art therapy also o¡ers
time, the author has collected a series of methods that can overcome the barrier
assignments that have proven e¡ective and of language. Many victims are unable
illustrative, and encountered least resistance to talk about what they have experi-
from the trainees. In 2006, this method enced. This may be caused by a variety
was laid down in the training manual: of factors, including: the incapability to
‘Coping with loss and trauma through art put experiences into words (particularly
therapy’ (Meijer-Degen, 2006). During the in young children); detachment from
trainings, the possibilities of using local physical and emotional experiences
materials are always explored. Clay, sand, (dissociation), which can be a coping
stone, feathers, charcoal and many other mechanism to master, minimise or
materials are often directly available, or tolerate stress; feelings of guilt and shame
available at low cost. (e.g. torture and/or having been forced
A special point of attention in each training to become an accomplice); practical
proved to be to teach the trainees to pay problems such as when trainees within a
attention to the (emotional) signi¢cance of group do not share a language or culture,
their creations for themselves, instead of and; fear of political consequences. In art
conforming to general ideas of the meaning therapy, each participant can give shape
of colours, of right and wrong, of beautiful to their own experiences. It allows
and ugly. Many trainees had to learn to be people to disclose and express what they
non-judgemental and/or not to adhere have experienced without the need for
exclusively to their own interpretations of spoken language.
artwork made by others. The focus during Practice example: ask the trainees to draw a
training was to connect with the meaning life line where the highlights and low points
that people themselves had given to their of their personal life are made visible. After

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 Meijer-Degen

the trainees have drawn their lifelines, the

trainees are invited to examine each other’s
drawings and to exchange (in couples) what
they have expressed.

Illustration 1: Life line (drawing by a

trainee in Cambodia) Illustration 3: Emotional maps created
by participants in Cameroon
2. Learning to re£ect on emotions
Art therapy encourages trainees to Art therapy does not allow the trainees
re£ect on their experiences and show to hide behind a shield of words.
genuine interest in the motivations Where some have no words to express
of others. Assignments such as: ‘the their traumatic experiences, others
day I will never forget’, or ‘the obstacles in use words abundantly to cover their feel-
my life’, provide opportunities for the ings and emotions. Some participants
trainees to exchange personal experi- start the training by asking a lot of
ences. questions, such as: ‘is art therapy evidence
based?’, or ‘is the trainer quali¢ed?’. Or they
may try to avoidexpressing their emotions
by indicatingthattheyarewellacquainted
with trauma theory, or that there is a
particular need for the newest western

Illustration 2: ‘The day I will never

forget’ (drawing by a participant from
Iraq)

Practice example: have the trainees draw or

paint an ‘emotional map’ that expresses the
emotions they feel at that moment, within a Illustration 4: Expressing emotions
circle. without words (the Netherlands)

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 Art therapy for mental health workers in areas affected by violence: a rarely explored resource
Intervention 2014, Volume 12, Number 1, Page 99 - 107

methods. This as a way to keep the 5. Developing an open attitude

unknown at a ‘safe’ distance. Usually, this Training provides opportunities for the
sort of resistance is overcome by the ¢rst trainees to experience that what is good
assignments, after which the participants for them, may not necessarily be good
are better able to give shape to their feel- for another.
ings, and are often surprised at the content Practice example: ask the trainees to create a
of their own images.This is due to the fact ‘supportingimage’thatcan helpin di⁄culttimes.
that in art therapy the ‘language’ of the During a training in Cameroon most images
image is used, allowing experience and contained religious elements. In discussion, it
emotionstobe made visible andaccessible. became clear that often aid workers also advised
3. Building on personal abilities and strengths their clients to pray frequently in di⁄cult times.
The methods of art therapy appeal to the However, some trainees created images of
trainees’own personal abilities, solutions nature, family, music and dance. In this way,
and creativity. when examining the drawings, it could be
Practice example: have the trainees close their made visible and be discussed that what is
eyes and create a scribbled line on paper. good for one, isn’t necessarily good for another.
Then, with their eyes open develop the line 6. Creating a safe space
into an animal.This assignment will stimulate Feelings of a lack of safety can be sur-
the trainees’ own abilities, solutions and mounted by giving the trainees time,
creativity. and by creating an atmosphere of trust.
This canbe done by allowing the trainees
to determine whether they want to
participate actively, or would rather
(at ¢rst) sit on the side and observe. This
approach can also be applied with
respect to the evaluation of the artwork.
Although a trainee’s work might raise
questions, the trainer should wait to pose
these until the trainee has decided to
share (their) experiences. It is important
to allow each trainee to work at their
own pace, and thereby retain control.
7. Breaking through existing hierarchies
A concomitant advantage of art therapy
trainings is that it can break through
Illustration 5: Assignment with existing hierarchies. Almost all trainees
scribbled line (training in Lebanon) are unfamiliar with art therapy, and
therefore start at the same level.
4. Overcoming helplessness and low self esteem Especially female and ‘lower tier’ trainees
Art therapy o¡ers the trainees the can realise their potential and thereby
possibility to actively participate, instead gain another position within the group.
of simply passively listening and taking 8. Encouraging trainees to discover local art
notes. A strong appeal is made to their One of the elements of the training is
own abilities and creativity. This can to have the trainees (re)discover the use
put an end to feelings of helplessness, of local art and materials from within
which are often ampli¢ed by traumatic their own culture. By focusing thereon,
experience, and as a result can reinforce the trainees are encouraged to have pride
the trainees’ self esteem. in their own background, and to help to

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 Meijer-Degen

restore traditions to their former glory. by the trainer were also highly appreciated.
One recurring assignment is to have the (See Box 1).
trainees search for expressions of art in
their surroundings. These can be hut Concluding remarks
decorations, decorated window frames, Art therapy training helps trainees to
masks, frescos and/or jewellery, but mobilise their own resources and provides
can also include music, festivals, dances them with a common approach and ‘non
and/or rituals. All too often this local, verbal language’ that helps to connect with
cultural richness has been disregarded clients from various cultural backgrounds,
or discarded as a result of war and/or and to open possibilities for change.
violence (Cohen, 2013). The training changed the attitude of the
counsellors from teaching and preaching to
Appraisal of the trainings exploring, together with the patients, what
As the trainings took place in many di¡erent was needed to feel better and what may help
countries, and with participants of many to tackle their problems. A major bene¢t
nationalities, it was not possible to systemati- of art therapy is that it creates space for
cally measure the e¡ectiveness of the train- unconscious processes. A patient’s art often
ing. Hence, the objective of the training to shows us what they are unable to articulate
stimulate the trainees to work with art verbally. Often when therapist and patient/
therapy was measured in terms of the client try to work in a problem focussed
satisfaction of the trainees, both during and manner, their vision becomes narrowed
after the trainings. and they may get stuck. Art therapy is
Informal evaluations showed predominantly an approach that allows perspectives to
positive results. In terms of personal open up, by inviting creativity. As one of
relevance, almost all trainings were highly the trainees remarked:
valued. Especially, the mutual cooperation
and the overall atmosphere had been ‘I think art therapy training was very valu-
experienced as helpful and usable. The able to all involved as it opened their minds
presentation and the information given to many other ways of communicating. It

Box 1: Some feedback from trainees

‘The training courses certainly helped to mobilise my own resources. Since I and the other partici-
pants in the courses worked with people from many different cultural backgrounds, whose spoken
language we did not share, we needed an approach, a language that could help us to connect with
clients and to open possibilities for change. In contrast to the more verbal training, the training in
art therapy provided me (and I dare say others) with those possibilities.’ Trainee from Namibia
‘ n important difference between art therapy training and more verbally oriented training courses
A
I took part in is that the former enabled me to experience the impact of the approach and the
methods on a personal level. I found that the training courses provided me with well founded
theoretical knowledge and, more importantly, provided me with an experience of the transformative
power of art therapy.’ Trainee from Iraqi Kurdistan
‘Recently I had a patient that was raped and could not express herself in words. I applied the
assignments from the art therapy training to this situation. As a result thereof she was able to
express herself to me through art.The training was very worthwhile to me.’ Trainee from Iraq

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 Art therapy for mental health workers in areas affected by violence: a rarely explored resource
Intervention 2014, Volume 12, Number 1, Page 99 - 107

gave them permission to be more creative, to countries and cultures. However, to date,
get out of their boxes of right and wrong, much of the opportunities created by art
and to find new and unusual ways to enjoy therapy remain under-exposed and under
themselves.’ utilised.
(trainee from Cameroon)

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Chu, V. (2010). Within the box: Cross-cultural

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Illustration 6: trainees from Iraqi
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Goodman, RF (2009). Creative arts therapies

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Illustration 7: Creating a board game in Psychotherapy, 3,167-179.
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 Meijer-Degen

di¡erent perspectives. In: J Wilson & B Drozdek £ew around freely and goats wondered about the
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1 Some exceptions are Chu (2010) who used art Fiety Meijer-Degen is an art therapist, residing
therapy with genocide survivors in Rwanda, and working in Amersfoort, the Netherlands.
and Byers (1996) who used art therapy with She is director and art psychotherapist for
children in theWestbank and Gaza. the Institute for Art Therapy & Expressive
2 For example, in 2003 in Ja¡na (northern Sri Psychotherapy (ICTEP), and is an advisor of
Lanka), the location of the training was a the Hijman Degen Foundation.
bombed school without a roof, where pigeons email: ¢ety@ictep.com

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