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ACQ
Volume 11, Number 3 2009
ACQ
uiring knowledge in speech, language and hearing
Figure 2. The car
Figure 3. Teddy plus
toys (Figure 3). Finally he drew a cannon, which he wanted
so he could “shoot everyone away”.
In his drawings he revealed his needs both for intimacy
(the teddy) and his need for control in the face of fears of
obliteration (the car and the cannon). This assessment led
to the development of an art and play activity which gave
him opportunity both for control and for connection with
his therapist. The activity, which extended over much of the
term, revolved around a remote-controlled Meccano car. He
wanted the car and was prepared to earn the kit by cooking
and serving lunch for the staff team (with the assistance of
the case manager). The kit consisted of 413 pieces that
he and the case manager assembled together over eight
weeks. He was more keen on driving than building the car
so a compromise was made by which he could drive the
partly built car for a while after each session of building. In
the building process, he took the role of mechanic, directing
the process, while the case manager assisted by sorting the
components and assisting with some of the fine motor tasks
that were too difficult for him.
In addition to building the car, the client and art therapist
worked together to make traffic signals (red, amber and
green) which were used in driving sessions to establish
external controls for the car. The car with wheels and a
partially finished body became an external representation
of the young person as a work in progress - who was able
to stop, start, and move around, subject to a set of non-
arbitrary external controls.
Discussion
The art therapist brings a framework that affirms the value of
art making as a means for both expression of complex
phenomena such as emotions and communication through
metaphor. While art therapy can be an intervention in its own
right, it particularly lends itself to application in a
multidisciplinary setting. Art making provides another
dimension to the verbal, behavioural, and medical
interventions that are characteristic of treatment of children
and adolescents with severe mental health problems.
The first example of the application of art therapy in a
specialist CYMHS service shows how art therapy can be
successfully integrated with a psychological intervention to
provide a rich group experience. Mindfulness is widely used
in contemporary evidence based psychological interventions
because it promotes self-awareness in a manner that is non-
threatening and typically anxiety reducing. The addition of art
therapy extends mindfulness into domains of expression and
communication. Art therapy promotes enhanced awareness
of emotions and providing a medium for communication
with peers about these emotions. In the creation of this
collaborative group activity, the art therapist and the
psychologist enhanced their practice frameworks and
created a coherent experience for participants that was both
enjoyable and an opportunity for learning and development.
The second example shows how the art therapist
can bring specific skills and techniques to the work of
case management. A core task in case management is
the development of a collaborative trusting relationship.
This enables the case manager to identify client needs,
develop a multidisciplinary treatment plan, and monitor the
effectiveness of the plan. Children with complex mental
health problems often struggle in purely verbal environments.
With such children, art and play provide a medium for
The drawn “case” then functions as a visual metaphor for
the child, making an abstract concept more concrete, and
providing the child with a way of both visually and verbally
representing him or herself. As the therapeutic engagement
develops, the art therapist as case manager invites the child
into an ongoing dialogue about the “case” using questions
such as “What have you been doing with the case this
week?”; “What do you want to get out of (put into) the case
this week?”; “How can I help you with the case this week?”
The “case” has a transitional role. It is the container of the
child’s problems, fears and worries as well as hopes and
expectations. However, it is not the whole child. The child
achieves a certain distance from the case and can join with
the case manager in working out how to deal with problems
that are either in the case or associated with the case. The
case manager is there to manage the case but not the child.
Artwork and play in assessment and the
therapeutic work of case management
The case manager is usually the primary individual therapist
(Kanter, 1989) and draws on the therapeutic framework and
repertoire of therapeutic techniques in which she or he has
been trained. When the case manager is an art therapist, it
follows that much of the individual work with the child will
utilise art therapy, as the following case illustration shows.
A 10-year-old boy with long history of severe emotional
and physical abuse and deprivation with impulse control,
attention deficit, and attachment problems was referred
to the service following multiple suspensions from primary
school. At the time of the referral he was incapable of
participating in normal classroom activities and was
spending just an hour or two each day in special one-to-
one learning activities. Even these sessions often ended in
eruptions and physically aggressive outbursts.
In the initial interview, he exhibited extreme anxiety, pacing
around the room unable to sit down at the table the art
therapist, as case manager, had prepared with art materials
on it. The case manager asked him “if you had three wishes
what would they be?” and suggested he use the big white-
board with a photocopying function to draw on – hoping
that the use of gross motor skills would dissipate his nervous
energy. He produced a car (Figure 2) including himself with
arms at the steering wheel but with no legs or foot-controls
for breaking or acceleration. He said he would like to own a
V8 with mag wheels. He then drew his second wish which
was a teddy with arms and legs and said he wanted more