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Ivo van der Velden & Mirjam Koops
Structure in word and image: combining narrative therapy and art therapy in groups of survivors of war
Ivo van der Velden & Mirjam Koops
The authors describe a programme for victims of war the somatic equivalents of their high level of structured around day care treatment that takes into arousal; account the need of patients for structure and at the 3. A social skills training group; same time makes it possible for them to re-experience 4. The combination of a ‘story’ group and art the trauma. This programme consists of a combination therapy; which is the main topic of this arti- of a storytelling group and art therapy. cle. The programme is ‘open’, which means that Keywords: psycho trauma, storytelling, nar- there is a regular in and out flux of partici- rative group psychotherapy, art therapy, testi- pants. mony, victims of war The participants are primarily first genera- tion survivors of World War II, mostly from Introduction the former Dutch East Indies. They suffered Centrum’45 is a Dutch centre for the treat- multiple traumatic experiences in their early ment of survivors of war and organized vio- childhood during the war, and in the course lence. The staff recently developed a type of of the subsequent migration from Indonesia treatment that offers structure while at the to the Netherlands. At an early stage in their same time enabling clients to address their lives, they were deprived of the necessary traumas in depth. Clients work, in a group family support to deal with these experiences. setting, on their own individual and specific The emphasis was on continuing life in the treatment goals. The acquisition of coping midst of loss. Therefore, these are people skills is therefore, strongly emphasized. who had a traumatic event early in life and The clients attend a set therapy programme who now are being impacted by their past. In once a week for a period of eight months most cases, they have maintained their origi- with the following components: nal survival strategies for an impressively 1. A task-oriented therapy group, in which long time. They now have difficulty organiz- clients agree upon and evaluate the specific ing and directing their lives, have a limited steps they will take towards accomplishing ability to move freely in society and therefore their treatment goals; are living limited social lives. They present a 2. Psychomotor therapy in a group setting, in variety of psychological complaints: anxiety, which clients learn how to deal better with depression, feeling pressured. They have
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problems with sleeping, suffer from night- strict rules. The atmosphere is tense, but also mares and flashbacks, and have problems in sympathetic. The group members clearly have the regulation of aggression. an emotional bond. After the session, they leave together for lunch, joking, sometimes The story group touching, and consoling each other. Five men and one woman are sitting in a room. Five Aim. The therapeutic aim of the story group are of Indonesian descent. Their ages are between 60 is to enable the participants to tell their trau- and 70. The two therapists enter. There is some jok- ma story within a safe setting. At first, stories ing that they are late. Then a tense silence ensues. tend to be too well polished, or show many ‘Jan, if I’m not mistaken it’s your turn’ says one of the gaps, while less essential details are magni- therapists. Jan sighs, ‘I’d better begin’. He tells the fied. Participants appear to control their emo- group about his early childhood in the internment tions and prevent flashbacks by using this camp: that his father had gone, his mother had style of story telling. However, in doing so, become hard and bitter, about the illness of his they also block working through the experi- younger sister, the hunger, the search for scraps of ence. Therefore, therapists intentionally food, and the public punishment of prisoners who were work to make the telling of the story an forced to sit and stare into the sun for hours on end. intense experience. Traumatized participants Group members sometimes nod in understanding. One would rather not deal with this intensity and of them is clearly holding back tears. The therapist therefore tend to structure the telling of their regularly interrupts the speaker. It seems impolite and life story so that they feel safe and under con- harsh to ask someone a series of painful questions and trol (Hunt & Robbins, 1998). to enquire about details, when it is plain to everyone Structure. The task-oriented character of day how difficult it is already. ‘How does the hunger treatment inherently contains a lot of struc- feel?’, ‘What is it specifically about your mother that ture. Additionally, there are certain specific tells you she has become so hard and bitter?’, ‘What rules for the story group. Only one partici- does your sister’s illness look like?’, and ‘Does anyone pant tells his or her1 story in the weekly one have any question to ask of Jan?’ Most group mem- hour-session. Who that will be is agreed bers remain ‘polite’, and do not ask anything, but one upon during the previous session and each of them tries to speak about his own camp experiences. will take his turn. There is always a back up One of the therapists stops him from doing so: ‘No in case the protagonist is not there, some- Andy, let us try to focus on Jan’s story and help him thing, which may well happen in a group cli- to deepen it’. Jan is clearly finding it difficult, as he is mate of avoidance. The ‘audience’ within the not permitted to tell his story the way he has done so group has its own task: they are expected to often before in his life, now he is unable to maintain support the protagonist in his story with his own safe tempo. When he has to speak about his explorative questions and brief responses. history in this manner, it almost feels as if his story is They can only bring in their own experiences happening in the present. He is not allowed to side- if this seems facilitative for the protagonist. step by talking about his failed son, or about the rejec- The vignette above shows how difficult a task tion of the Dutch that he felt when he arrived in the this can be. The hard questions are usually Netherlands. left for the therapists to ask. There may also be a cultural factor here. In Indonesian cul- Above is a brief example of how a typical story ture (and in many others) one is expected not group session may unfold. Someone tells his to ask questions, which might leave the other life story, but does so within a framework of person sad, or angry.
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During the course of treatment, each client exchange ‘services’, like making a ‘spekkoek’ tells his story several times. The first time the (Indonesian cake) for someone. There is focus is on the actual traumatic events; the always someone who appears to be assigned second time explores events before and after the ‘father’ or ‘mother’ role, and people dis- the trauma, on up to the present time. If pos- cuss this dynamic openly. Within this partic- sible, there is an exploration of the influence ular day-treatment programme, there is a lot of the past on the present: how do past of attention given to the termination of treat- ‘scripts’ influence the experience of the pres- ment, and saying goodbye. People tend to ent? It sometimes happens that someone can- give presents at these occasions, something not tell his story in a single session. As an which is also not encouraged. After termina- exception to the rule, it can then be decided tion, there are still frequent contacts between to continue the story next time. However, in former group members. order for the participants to learn how to gain Preparation for telling the life-story. This prepara- maximum control, it is preferred that these tion occurs in a variety of ways. Before telling experiences be consciously closed off and their life-story, the participants construct their then purposely opened up again later. own lifeline during art therapy3. Clients are New participants do not tell their stories encouraged to bring objects that are connect- immediately, but will first observe and wit- ed in some way to the situation in which the ness the others during their first few meet- traumatic events took place (photos, a rice ings. In the art therapy group, they will focus bowl from the camp, etc.). They are also initially on constructing their life-line (see that encouraged to research the past, for instance, section). In that way, they gradually by speaking with family members that in approach their own traumatic material. some way were involved in their traumatic The story should not be directed at an indi- past. vidual therapist, but much more at an ‘audi- Sometimes, when it concerns particularly dif- ence’ with whom one feels a strong bond ficult, shameful, or intensely painful memo- How telling the story is facilitated. The suggestion ries, it is possible to express these parts of the ‘tell me about it’ will usually only have thera- life-story with the help of behavioural expo- peutic effects in an atmosphere of mutual sure: an intense, prolonged focus on the support among group members. Such an avoided stimuli and memories. This takes atmosphere gradually develops during the place in individual sessions with a therapist course of treatment, as group members’ are (not necessarily a psychotherapist); psy- continuously assisting each other with self- chomotor therapy and art therapy can also be imposed tasks and targets that flow from used to arrange a form of ‘prolonged expo- their treatment goals. After a while, this sure’. Finally, a participant may decide not to becomes a sort of group culture, which is talk about some aspect of their experience in transferred onto new participants2 and pro- the story group or may not be able to do so. vides the support needed to facilitate the sto- In that case, we usually suggest that he/she rytelling. There are frequent contacts attempts to work on this non-verbally, within between group members outside of the treat- art therapy. ment situation, although this is neither The attitude and interventions of the therapists. Both encouraged, nor discouraged, by the staff. At the group therapist and the art therapist are times, ex-group members are invited for present in the story group, and in the art informal meetings. Sometimes people group. The group therapist will usually have
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a directing role and the art therapist a sup- appears to avoid emotional matters. For portive role. Through their model-function, example: telling the story in an impersonal or the therapists will have to convey the essence stereotypical manner with little feeling (as if it of their approach: to confront the painful has been told hundreds of times before), material within the safety of the treatment telling the story very quickly, being stuck in structure. Painful memories can and will be the story, or dwelling endlessly on seemingly touched upon openly and directly. Direct and irrelevant details. searching questions will be asked. The thera- Apart from asking questions, the therapist pists may probe for details of the traumatic can stimulate the other group members to experience, or ask questions that help some- ask questions as well. These will usually be one to get involved in his or her own story. the kind of questions aimed at collecting As the story often is told in a stereotypical information that is more specific. The asking fashion with gaps and omissions, the thera- of questions has an important function for pist will attempt to examine the events from group members: it helps them to keep some several different perspectives. For example, if distance to the story of the protagonist, and it the description is mainly in images, the ther- may also help to control their own flashbacks apists may ask about sounds (‘how did the which may be triggered by identification with voice of this Japanese soldier actually the protagonist, or their story. sound?’). Continuously, the therapists are also search- The life-story is often presented as a string of ing for continuity (Dasberg, Batura & Amit, consecutive events: ‘first-this-happened-and- 2001). Events never exist in and by them- then-he-did-that’. The therapists will attempt selves, there is always a ‘before’ and an ‘after’. to bring the protagonist back into the story as Recurring themes are pointed out, if possible. someone with his own perceptions, his own In the interest of continuity, the therapists’ thoughts and feelings, his own ability to attention remains focused on the protagonist, choose and his own will power. This is par- unless the atmosphere in the group requires ticularly important with respect to experi- intervention. Sometimes there may be an ences in which force and loss of self-control avoidant attitude in the group. Alternatively, were an essential part. The therapists will the protagonist does not feel free or safe in attempt to bring out multiple interpretations the presence of some group members. In and attributions of the same experiences such situations, the therapists will briefly pay (Jefferson, 2000). attention to the group process. Meanwhile, the therapist tries to be vigilant for so-called ‘screen memories’. This is where The art therapy one painful memory ‘screens’ another, even The group sits in a circle around a table. Without more painful memory preventing it’s coming words, without overt agreement it is clear who will sit into full awareness. For instance, it may be where. The atmosphere is relaxed, and there is talk- easier to remember being mistreated by a ing and laughter. We begin with a brief chat to find camp guard than to remember being mis- out what each person has been able to accomplish in treated by your father. In the same way, his or her work. Then, the therapist gives directions so memories of poverty may screen earlier and everyone can continue with a clear focus. Questions more painful memories of emotional neglect. asked may be along the lines of; ‘how do I go about The therapists try to mould the questions to making a support project. I cannot think of anything address the ways in which the protagonist positive without remembering something bad...?’ The
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work is taken from the drawers and the group begins. late contact with more hidden emotions4. The atmosphere is quiet and everyone is concentrated In working with tools and materials, one can on his own work. The first half hour is spent focusing practice dealing with problems in a different on the ‘trauma project’. Time quickly passes. One way. One of the most important outcomes is group member switches to their support project after a greater flexibility5. short 10 minutes, as he is no longer able to cope with Structure. The art therapy sessions lasts one the trauma project, while someone else finds it hard to hour. Everyone works individually on his tear themselves away from it. One woman begins to own project, using either the easel, or the cry. She is painting an image of herself amidst bom- table. People work on very clearly defined bardments, together with other painful images from assignments. The first three sessions are her memory. She is shocked at her own reaction, ‘as a spent on the ‘life line’ - an assignment that child I always had to keep quiet - forget everything I can be seen as preparation for the first telling saw and heard. I now rarely feel any emotions when of the life story in the story group. The next I have these memories, not even last week when I told sessions are spent on the ‘trauma project’ and my story in the group. Now that I am painting myself, the ‘support project’ (explained below). The I can see myself again... when I was a little girl - and first half hour of every meeting is spent on everything comes very close to me. I can finally cry’. the trauma project, and the second half hour The work is stored away in a personal folder, and the on the support project. During the last ses- meeting is closed by jointly reviewing the work that sions, the art therapy group is used to prepare has been completed over the past hour. a ritual ending of the treatment programme. The lifeline. The construction of the lifeline is Aim. In the art therapy group participants are intended to further construct a better sense of expected to depict their own life story. It is the past. By presenting their life story in not a group in which the story is communi- chronological order, clients can also structure cated to the other group members, but a set- their memories. In doing so, insight may be ting where each searches for meaningful gained into the broad outlines and recurrent images in themselves - those that will stimu- themes, and a connection can be made
Figure 1: The hands of the client’s mother are depicted. At this stage the work is unfinished and a Bible will later be added. His mother would often read to him from the Bible when this client was in the camp.
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between past and present. By assigning colours to the different periods of life, differ- ence and nuance is expressed in emotional life (happy and unhappy periods). People work on this assignment three or four times. When this is completed, the participant is ready to tell his or her life story in the story group (de Vries-Geervliet, 2000). Trauma project. The aim in working on the trauma project is to search for those memo- ries of traumatic experiences that are the most charged with anxiety, and that are the most actively avoided. Different techniques, materials, and colours are utilized in order to make the recollection of the traumatic experi- ence as vivid as possible. Physically kneading clay with one’s hands provides a physical connection to the material; as a result, the subject theme may be experienced in a more physical way. Clients may spend a long time on seemingly Figure 2: A client sculpted out of clay an image of insignificant details of a traumatic experience, himself at a time he was forced to witness a mass exe- thereby avoiding more central, and usually cution. In sculpting the image, he came very close to more painful, aspects. If that happens, the his former emotions, which until then, his memories therapist will try to make them aware of this had been like a ‘grey amorphous mass’. and stimulate them to look at these difficult, but important aspects. An alternative is to Alternating between support and trauma. Within offer a different medium, which makes it art therapy sessions, we work for half an harder to work on details. hour on the trauma, followed by half an hour Support project. The aim of working on a sup- on the support project. Both client and thera- port project is to mobilize positive forces and pist keep track of this. It is important to find qualities. In this project, a person’s healthy the right balance between avoidance on the side is emphasized, and participants may dis- one hand, and endlessly working on the trau- cover the source of their strength to continue ma, on the other. The client is stimulated to and survive. Many of the support projects make these choices themselves, but if this is deal with pre-war people and experiences. difficult, a clock may be used. When the time Frequent themes are parents (often mother), for working on the trauma project is past, the religion, and nature. Work on the support client is asked to put it to the side. It is impor- project is important in regaining control, par- tant to keep the trauma project nearby with- ticularly as it is combined with work on the in the session; as a symbolic acceptance of the trauma project. Participants are stimulated to trauma as something that is always present, find and choose supportive themes in their as something that is a part of the client. life themselves, but frequently need direction Putting the trauma object away and out of from the therapists. sight would be like a renewed avoidance.
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Attitude and interventions of the therapists. Both in attention and tells his or her story. All eyes the story group and in the art therapy group are focused on the speaker while the others the focus remains on the individual. In both listen, and perhaps ask questions. groups, it is considered important to confront The story group provides an overview of the traumatic material from the safety of treat- personal history of the participants with a lot ment structure. The art therapist stimulates of opportunity to probe for details. Specific the client to use certain materials, and helps aspects of the story may be tackled in art the client to search for those images that are therapy. By adding art therapy, it becomes associated with the traumatic experience. possible to continue themes for extended While sitting next to the client and discussing periods. Words are spoken in seconds, but his work there is ample opportunity to probe creating an image takes much more time. for details, such as: ‘what did the surroundings This may intensify the therapy process. look like?’, ‘what colours did you see?’, ‘where did Images made in art therapy are tangible, con- you stand?’, and ‘where were the others?’. crete. They can be stored away physically, The material choice is jointly made between taken out again, or shown to friends. They client and therapist. Some find it difficult to can even be thrown away, or destroyed. work with clay as can sometimes release mem- The content of what is being expressed is ories of earth and corpses. When this kind of often less important than the manner in fear occurs the decision can be taken to make which this expression occurs. Most clients a drawing of the trauma first, then, at a later have spoken about their wartime experiences stage this can be used as a starting point for before, but often in a highly stereotypical work with clay. People often attempt to control manner. In this process, they are encouraged their emotions by working with pencil and a to step outside of this stereotypical frame ruler. Working with brush and paint is much (Laub & Podell, 1995). This may give rise to more difficult because more control has to be anxiety, but also offers a new opportunity for relinquished. Colours are more intensely expe- working through the experience. New, and rienced, and may bring someone closer to yet untouched aspects of traumatic experi- their traumatic experiences. ence, may come to the fore. Clients increas- ingly become aware of the more basic cogni- The combination of story group tions they cling to about themselves, others, and art therapy and the world (Mishara, 1995). The combination of therapies is meant to Participants seem very committed to the ther- integrate recollections of traumatic events in apy and the groups tend to be highly cohe- both a verbal, and a non-verbal way, and for sive. This provides the safe basis from which both methods to complement each other. the participants can confront anxiety and The two therapists run the story group and gain a new perspective on life, as well as dis- the art therapy group jointly. In this way, they engage from misery, and to have fun. can maintain an overview of the therapy process in both. References6 The atmosphere in each therapy group is Dasberg, H., Bartura, J. & Amit, Y. (2001). noticeably different. The story group usually Narrative group therapy with aging child sur- has a more palpable tension, while the mood vivors of the Holocaust. Israel Journal of in art therapy tends to be more relaxed. In Psychiatry and Related Sciences, 38, 27 - 35. the story group one person is the centre of
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De Vries-Geervliet, L. (2000). Over trauma’s gespro- their language; they keep repeating them- ken. Baarn: Nelissen. selves or just cannot find the words to express what they want to say. In art therapy Hunt, N. and Robbins, I (1998). Telling stories of we work with a ‘language of imagery’ the war: aging veterans coping with their mem- through which communication and explo- ories through narrative, Oral History, 57 - 63. ration may at last become possible. 5 Often people prefer to work with pencil and Jefferson, A.M. (2000). Remembering and re-story- a ruler to express the images in a very precise ing: an exploration of memory and narrative in and controlled way. The suggestion instead relation to psychotherapy with torture victims. to paint or to draw may be difficult and Torture, 10, 107 - 111. increase anxiety. Old patterns have to be relinquished, which results in fear of loss of Laub, D. & Podell, D. (1995) Art and Trauma. control. What emerges when they are able to International Journal of Psychoanalysis, 76, 991 - do so, is the ability to work more freely, less 1005. controlled, and with more authenticity. Working with a brush gives less control, Mishara, A.L. (1995). Narrative and psychothera- while working with colour stimulates the py: the phenomenology of healing. American emotions in a way that a grey pencil doesn’t. Journal of Psychotherapy, 49, 180 - 195. In this way flexibility is encouraged. 6 A more extensive reference list can be ordered through the first author: ivdv@cen- 1 In the following, on behalf of readability, the trum45.nl masculine and the feminine will both be rep- resented by the masculine when the text is applicable to both sexes. The masculine in this article feels somewhat more comfortable because most group members are male. 2 This is one of the reasons why an open group setting is important. In a closed group such a group-culture would have to be rebuilt Ivo van der Velden (1952) is psychologist and time and again. psychotherapist. He is working as a psychothera- 3 Apart from being a preparation for telling pist and chief education and training at Centrum the story, we also believe that traumatic expe- ‘45. E-mail: [email protected] riences should first be explicitly placed with- Mirjam Koops (1973) is an art therapist and is in the life-story. These experiences have often working as an art therapist at Centrum’45, become split off, dissociated and fragmented, where she is focusing on first generation war vic- as a result of which they no longer form part tims and refugees who have stayed for a longer of the flow of life. time in the Netherlands. She also worked abroad 4 Often early memories are stored in a more for the organization ‘War Child’ (Sudan, sensory or bodily way. The same is true for Ingushetia) and is active in an organization that early traumatic memories. Images may form promotes the quality of life for refugees and asylum the ‘key’ to these memories and the accom- seekers in the Netherlands by means of art, drama, panying emotions. and music. E-mail: [email protected] Moreover, people are sometimes stuck in
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