The Importance of the Self-Body Image
in Survivors of Sexual Assault with PTSD
Using Art Therapy Techniques
Although visual expressions have been basic to humanity throughout history, art therapy did not emerge as a distinct profession until the 1930's. At the beginning of the 20th Century, psychiatrists became interested in the art work done by patients, and studied it to see if there was a link between the art and the illness of their patients. At this same time, art educators were discovering that the free and spontaneous art expression of children represented both emotional and symbolic communications. Since then, the profession of art therapy has grown into an effective and important method of communication, assessment, and treatment with many populations, including health care and mental illness.
Art Therapy as used for PTSD
Post Traumatic Stress Disorder (PTSD) involves a pattern of symptoms that some individuals develop after experiencing a traumatic event such as sexual assault. Symptoms of PTSD include repeated thoughts of the assault; memories and nightmares; avoidance of thoughts, feelings, and situations related to the assault; and increased arousal (e.g., difficulty sleeping and concentrating, jumpiness, irritability). One study that examined PTSD symptoms among women who were raped found that 94% of women experienced these symptoms during the two weeks immediately following the rape. Nine months later, about 30% of the women were still reporting this pattern of symptoms. The National Women's Study reported that almost 1/3 of all rape victims develop PTSD sometime during their lives and 11% of rape victims currently suffer from the disorder.
Art Therapy in PTSD Survivors
One important aspect of Art Therapy is the creation of a safe space where these traumatic feelings can be processed. Sometimes the verbal skill is lacking to describe traumatic experiences and by creating art, the person can feel more confident .
Brett and Ostroff focused on the imagery processes in PTSD and a framework for treatment. Research has found that traumatic experiences are encoded in non-verbal imagery and that it is often difficult to verbalize the experiences because traumatic experiences have been found to be encoded in non-verbal imagery pathways of the mind. These images show up in both dreams and artwork.
Art Therapy has been used to help War Veterans, Refugees, people who survived Natural Disasters and Sexual Assault/Domestic Violence Survivors – people who are susceptible to PTSD.
Art Therapy in SA Survivors with PTSD
Art Therapy is not a new idea when it comes to survivors of sexual assault. In the 1980's group art therapy was used in centers for survivors of sexual assault. Models have even been created to help women address the problems that occur after such an assault.
Many domestic violence and sexual assault centers have art therapists to help process the trauma that has occurred. There are even national art therapy projects afforded to survivors. The Clostheline Project is particularly well known and many college campuses participate in it.
The Role Dreams Play
Dreams or, more specifically, nightmares are a major role in the life of someone who has PTSD. As such, a little time needs to be devoted to dreams relating to PTSD. Dreams are a unique view on trauma and its effects. Dreams show a changed version of events that is often distorted but can bring troubles into resolution. This can be both diagnostic and therapeutic. Earnest Hartman proposes that PTSD dreams are not 'truly nightmares but a memory intrusion into dreams as well as waking life'
Typical dreams with PTSD
A typical PTSD nightmare is recurrent with a variant of the traumatic scene happening over and over again for years. Hartman argues that they are not nightmares at all, but what he classifies as "memory intrusions" because of how they differ from normal nightmares with the repetitive quality and time of occurrence. In laboratory settings PTSD Nightmares are classified differently from night terrors or nightmares as they can occur in both non-REM sleep and REM sleep. Hartman says that "a repetitive nightmare of PTSD is an encapsulated memory that can intrude into consciousness during sleep or during waking"
Typical Dreams with Survivors
There are two main different patterns of dreams of survivors of sexual abuse. One pattern is frequent repetitive nightmares. The other pattern identified by Susan Brown is the confounding and confusion of sex and aggression in the same dream. There are four different dream stages that a survivor goes through. The first phase is self protection, the second acknowledgment, the third of fax and the fourth growth in understanding finally leading to renegotiation.9
• Self Protection: the dreamer makes clear that they do not want to go through the experience of admitting what has happened to them. The dreams normally consist of pushing away and denial.
• Acknowledgement: the dreamer replays the assault that has occurred. The dreams often play out the memory of the assault.
• Effects: the person dreams about how they feel in the current situation related to the sexual assault. An example may be a person feeling like they are covered in cement.
• Growth and Understanding: In this phase, the dreamer sees something differently and from a different point of view.
• Renegotiation: The survivor comes to terms with what has happened to her.
Art Therapy Involving Dreams
Dream imagery is very strong among survivors of sexual assault, and art therapy helps bring these dream images into the waking world to be processed. Focusing on the dream helps contain some of its unpleasant feelings. Getting the imagery out and looking at it makes dreams more approachable. Having a choice over how to express the dream makes people curious.
For example, crayons allow the sense of control, where paint is more expressive. A sharp pencil encourages detail. By using art, the dream begins to evolve. The art is not just a response to the dream but allows it to continue. Some parts of the dream show greater emphasis and others are added, left out or diminished. This interacting with the dream is important and can be empowering.
Types of Art Therapy Projects used for Survivors
Various methods of art therapy are employed: graphic narratives, drawings of the traumatic events, drawings of dreams and drawings of the empowered self. Each method focuses on the fact that it is often difficult to verbalize the experiences because traumatic experiences have been found to be encoded in non-verbal imagery pathways of the mind.6 Of these, work with the self-body image therapy stands out.
The survivor's self-body image becomes very important when working with sexual assault. The Self-Body Image can be used to determine if a person has been sexually abused, using the Manchover Draw-A-Person Test. It is also possible to create an image that integrates a traumatic image with the whole self.
Self-Body Image #1
In a study performed by Rachel Lev-Wiesel , the common traits of images drawn by both male and female survivors were analyzed. The Manchover Draw-A-Person test was used. In this test Gillespie feels that the request to draw a person lets the patient freely chose all of the aspects of the person. In their study they had 10 women and 10 men child sexual abuse survivors and a group of 10 people who were not abused as the control. The following areas were used as indicators of baseline: eyes, genitals, hands, and arms.
In this experiment, the face line showed a double chin or cheek that was either empty or shaded and was in all drawings of sexual abuse survivors. In most survivors the eyes were either shaded, hollowed dotted or omitted. There was also an addition of a barrier such as a large belt between the lower and upper body. When looking at the hands and arms most, were clingy, cut off, detached or omitted.
Self-Body Image #2
In another Self-body-Image exercise, the women were asked to focus on their empowered and disempowered self . Beth A. Stone wrote about her work with the empowered/disempowered self. This exercise was recreated by the author using two women who have PTSD symptoms.
The women were first asked to draw a picture of their empowered self without speaking.
Both pictures are very bright in color and the feet are firmly planted on the ground.
The women were then asked to draw a picture of their disempowered self in silence.
Both pictures are dark in color, show a disoriented background and have their feet standing askew. Both drawings have words written on them.
Next the women were asked to have a conversation between the empowered self and the disempowered self.
The women were then asked to draw a picture of the conversation.
Link to The Images
Beth Stone found that the empowered self is consistently larger than the disempowered self. The disempowered self lacks color and is darker than the image of the empowered self. The disempowered self is also bent or closed-up in stance and the feet are often not placed on the ground. Our test has shown the same results.
Survivor comments on the use of Art Therapy
Many survivors of PTSD and Sexual Assault have used imagery to help them heal. A group of survivors were asked about the impact of art in their life and their recovery. Their comments are shown below. Often times they use art to replace words, which cannot convey the hurt that they have survived.
"I have never done art therapy, but art is my therapy. Through artwork you can let out what you can't put in words, because sometimes there aren't words adequate of the pain, or it is too hard to put in words."
"Art therapy helped me to be less judgemental[sic]of myself. When I first started, I would hold an oil pastel/pencil/paintbrush over the paper, too afraid to even make the first mark. With the gentle encouragement from my art therapist, "It doesn't matter how it looks; it's the process", I was finally able to let go enough to just let my art happen. Once I did that, I was able to get at some pretty deeply hidden emotions, and I was able to talk about those emotions as well."
"I have been in Art Therapy for 2 years. I came in with no words, the complete innability[sic] to speak or express myself. Art became my voice when I could not speak. If it wasn't for being able to freely express my feelings on paper without judgement- [sic]be it morbid, happy, sad, or angry, I don't think I would be here right now"
"Making art may also help me express feelings I'm not allowed to express otherwise. Sometimes I paint myself and those pictures really show my emotions, my sadness, my fear and my pain.
Most of my pictures are still happy ones. I paint things I like. I do a lot nature pictures. I also make portraits of people I admire, last week I painted Tori Amos, for instance. Making those makes me feel better. "
"Making pictures gives me energy and joy even in the worst times.
It also raises my self esteem. Often I may feel that I'm bad and weak but when I look at my pictures I appreciate myself more. I'm not just a victim, I'm also an artist, I have creativity, power and skills beyond my wounds and experiences. My abuser destroyed most of my life but he couldn't destroy my creativity. And I am actually better than him in something."
The majority of PTSD symptoms revolve around imagery. The nightmares, flashbacks and intrusive thoughts are often examples of survivors reliving the imagery of what occurred to them. It is possible to tell if someone has been sexually abused based on their drawing of their own self. Images of the self are also used to help survivors incorporate what has happened to them into their daily lives and has helped them to regain power. Art Therapy has been shown to be a powerful tool when resolving issues around PTSD. Art Therapy has been introduced to Rape Crisis Centers and work towards helping these women achieve peace.
Vab der Kolk, B.A. (1994) Trauma. Memory and the Self. Lecture. Australia and New Zealand Association of Psychotherapy, Westmead Hospital, NSW, Australia
Breat, E.A., & Ostroff, R (1985) Imagery and PTSD: An overview. American Journal of Psychiatry, 142,417-424
Ledoux, J.E. (1994) 'Cognitive-emotional Interactions in the brain.' In p. Elkman and R. Fadison (eds) The Name of emotion, Fundamental Questions. New York: Oxford University Press
Courtois, C.A. (1988) Healing the Incest Wound: Adult Survivors in Therapy. New York: W. W. Norton
Spring, D. (1993) Shattered Images: The Phenomenological Language of Sexual Trauma. Chicago: Magnolia Street
Hartman, Earnest 'Who Develops PTSD Nightmares and Who Doesn't', Trauma and Dreams: Cambrige: Harvard University Press
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Brown, S. 1988 The dreams of women molested as children. Doctorial Dissertation, The Wright Institute
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Lev-Wiesel, "The Use of the Machover Draw-A-Person Test in Detecting Adult Survivors of Sexual Abuse: A Pilot Study.
Stone, Beth A. "Self body Image and PTSD in Australian Spanish Speaking Trauma and Torture Survivors: Empowerment through Imagery-Art-Dialog; Tapestry of Cultural Issues in Art Therapy. ed. Hiscox, Anna R. and Calisch, Abby C. Philadelphia:Jessica Kingsley Publishers