ATHABASCA UNIVERSITY
UNIVERSITY OF CALGARY
UNIVERSITY OF LETHBRIDGE
THE ART OF BEING SPIRITED: A GROUP PSYCHOEDUCATIONAL/ART
THERAPY GUIDE FOR USE WITH ADOLESCENTS WITH EATING DISORDERS
BY
ELIZABETH MAY YOUNG MCKENNA
A Final Project submitted to the
Campus Alberta Applied Psychology: Counseling Initiative
in partial fulfillment of the requirements for the degree of
MASTER OF COUNSELING
Alberta
(November) (2005)
All rights reserved.
This work may not be reproduced in whole or part by photocopy or other means without
permission of the author.
ii
iii
ABSTRACT
This project is a guide that combines spiritual, cognitive, creative, expressive and experiential elements into a group process to help health care professionals support adolescents with an eating disorder. The process embraces a holistic approach towards therapeutic interventions that incorporates Eastern and Western philosophies towards healing and art history with cross cultural links to develop the critical being through mindfulness practice, consciousness raising and communal experiential processes.
Literature reviews on spirituality, eating disorders, art therapy, creativity, critical thinking, self and group process identify themes, topics and strategies which form the foundation for interventions. Theoretical underpinnings, ethic of care, suggested topics, format for sessions, psychoeducational material for facilitators and participants, and ways to evaluate the product, process and facilitator are included.
iv
DEDICATION
To my husband for his love, fidelity, acerbic wit, sense of humour and unwavering support and encouragement. To my children Nairn, Noel and Kirsty who have taught me the most of what I know about adolescents, and forced me to embrace change. To my siblings for providing a good model for what it means to be a family. To my Canadian/Scottish clan – you know who you are! To all the parents who do the best they can to raise children in a world that is often ill equipped to support them. And lastly to my mother, one of the wisest women I know for her incredible fortitude, strength of character, integrity and insight on human nature. I honour your legacy!
v
ACKNOWLEDGMENTS
I owe a deep debt of gratitude to Pat Roles for agreeing to be my supervisor at Childrens’ and
Women’s Hospital in Vancouver, for sharing so generously her clinical knowledge and skills in working with eating disorders, giving up her art therapy space so that I could learn, and always finding the right thing to say to push me further in my professional growth. To Dr.
Pierre Leichner, Dr. Ron Manley, Dr. Jorge Pinzon, Dr. Glen Freedman, Dr. Carolyn Nesbitt and all the nursing and support staff in the Children’s and Women’s Hospital Adolescent
Eating Disorders program who shared their knowledge and expertise with me – I am the richer for it. Particularly, I am indebted to my husband Brian and my supervisor Ross Laird who gave me feedback on content, language and structure which added to the richness of this document. To my friend Wilma Bates a special thanks for editing several drafts. I also wish to thank my committee members and the staff within the program for their support, particularly Dawn McBride (Second Reader), Tony Mishra (a computer whiz and very patient man), and Paul Pival and Marvel Nash (Librarians). Finally, I need to acknowledge a deep indebtedness to all the individuals and their families who shared parts of their lives with me. I am changed forever by the experience, honoured to have shared space with you, and humbled by the faith that you placed in me.
vi
TABLE OF CONTENTS
ABSTRACT …………………………………………………………………… ….. iv
DEDICATION…………………………………………………………………. ….. v
ACKNOWLEDGEMENT………………………………………………………….. vi
TABLE OF CONTENTS…………………………………………………………… vii
LIST OF FIGURES ………………………………………………………………… xvi
CHAPTER I: INTRODUCTION
Introduction………………………………………………………………………….. 17
Introduction to the Guide ……………………………………………………….. 24
Problem Statement…………………………………………………………….... 25
Rationale………………………………………………………………………… 26
The Purpose of Spiritually Focused Workshops………………………………… 28
The Structure of the Guide………………………………………………………. 29
A Shift in Focus and Intention…………………………………………………... 30
About the Author………………………………………………………………...... 32
Personal Philosophy – Becoming……………………………………………….. 34
An Optimist at Heart…………………………………………………………….. 34
CHAPTER II: THEORETICAL FOUNDATION
Creative, Self-Determined Growth Across the Lifespan………………………… 36
Human Nature ………………………………………………………………….. 37
Seeds of Pathology……………………………………………………………... 37
Working Alliance………………………………………………………………. 39
General Goals of Therapy…………………………………………………….... 40
vii
A Cultural Perspective for Therapeutic Counseling……………………………….. 43
Internalized Culture and Worldview…………………………………………..... 45
CHAPTER III: ETHICS
A Model for the Highest Ethic of Care ….…………………………………………. 49
A Motivational Approach for Change …………………………………………. 57
Motivational Enhancement Therapy …………………………………………… 57
Stages of Change Model ……………………………………………………….. 58
Motivational Interviewing Model ………………………………………………. 61
A Narrative Approach …………………………………………………………… 65
CHAPTER IV: LITERATURE REVIEW – SELF
The Notion of Self ……………………………………………………………… 69
The Adolescent Girls’ Sense of Self ……………………………………………. 73
CHAPTER V: LITERATURE REVIEW - SPIRITUALITY
The Spiritual Journey……………………………………………………………….. 79
What is Spirituality?...... 80
Spiritual Assessment and Intervention……………………………………………… 81
The Link Between Spirituality and Health………………………………………….. 82
A Historical Connection to Spiritual Healing……………………………………….. 84
An Aboriginal Connection……………………………………………………….. 84
An Asian Connection…………………………………………………………….. 85
A Western Connection…………………………………………………………… 85
The Spiritual Connection to Eating Disorders………………………………………. 86
Down Through the Ages………………………………………………………… 86
viii
The Spiritual Connection Today………………………………………………… 88
In Search of the Spiritual Life……………………………………………………….. 89
A New Definition of Spirituality…………………………………………………….. 90
The Role of Faith…………………………………………………………………….. 93
The Value of Truth…………………………………………………………………… 95
The Power of Forgiveness…………………………………………………………… 97
Limitations of a Spiritual Approach…………………………………………………. 98
Spiritual Themes in Eating Disorders……………………………………………….. 99
CHAPTER VI: LITERATURE REVIEW – EATING DISORDERS
What Are Eating Disorders?...... 102
Prognosis………………………………………………………………………… 102
Recovery………………………………………………………………………… 103
Mortality………………………………………………………………………… 103
Age of Onset……………………………………………………………………. 104
Food Avoidance Tactics………………………………………………………… 104
Increased Risk of Suicide……………………………………………………….. 105
Co-Morbid Psychiatric Illnesses………………………………………………… 105
Increased Social Isolation……………………………………………………….. 106
Other Substance Use…………………………………………………………….. 106
A Historical Overview………………………………………………………………. 107
Changes Over the Last Twenty-Five Years…………………………………………. 108
Diagnosis………………………………………………………………………… 108
Etiology………………………………………………………………………….. 108
ix
Treatment………………………………………………………………………… 109
Medications………………………………………………………………………. 109
The Diagnostic and Statistical Manual of Mental Disorders Criteria………………… 111
DSM-IV Criteria – Anorexia Nervosa…………………………………………… 112
DSM-IV Criteria – Bulimia Nervosa……………………………………………. 112
DSM-IV Criteria – Eating Disorders Not Otherwise Specified…………………. 113
DSM-VI - Developmental Risks………………………………………………… 114
An Alternative Classification – Great Ormond Street Criterion……………………. 114
Anorexia Nervosa…………………………………………………………………… 116
Medical Implications……………………………………………………………. 117
Bulimia Nervosa…………………………………………………………………….. 119
Medical Implications……………………………………………………………. 120
Socio-Cultural Factors………………………………………………………………. 121
Advertising……………………………………………………………………… 122
Fashion…………………………………………………………………………... 124
A Cultural Link………………………………………………………………….. 124
Eating Disorders - The Pros and Cons………………………………………………. 126
Eating Disorders - Recurring Themes……………………………………………….. 131
Perfectionism…………………………………………………………………….. 131
Hopelessness and Helplessness………………………………………………….. 132
A Sense of Control……………………………………………………………….. 132
Ambivalence……………………………………………………………………… 133
Issues for Future Consideration……………………………………………………… 133
x
CHAPTER VII: LITERATURE REVIEW – ART THERAPY
Art Therapy………………………………………………………………………….. 135
Historical Overview……………………………………………………………… 138
Art Product Versus Art Process………………………………………………….. 139
Evolution…………………………………………………………………………. 142
Today…………………………………………………………………………….. 144
Why is Art Therapy Important?...... 146
Goals of Art Therapy…………………………………………………………….. 149
Tools of the Trade………………………………………………………………... 149
The Use of Art Therapy with Eating Disorders……………………………………… 151
Limitations of the Experiential Process……………………………………………… 154
Observations…………………………………………………………………………. 155
CHAPTER VIII: LITERATURE REVIEW – CREATIVITY
Origins of Creativity…………………………………………………………………. 159
Social Psychology………………………………………………………………... 163
Narrative Perspective…………………………………………………………….. 163
Constructivist Meaning Making…………………………………………………. 163
Flow Theory……………………………………………………………………… 164
Creativity as a Process of Self-Actualization……………………………………. 164
Art Therapy and Creativity – A Special Connection………………………………… 165
Creativity/Art Therapy – The Role of the Unconscious………………………… 165
Creativity/Art Therapy - The Transitional Object………………………………. 166
Creativity/Art Therapy – Tension and Building Ego Strength………………….. 166
xi
Creativity/Art Therapy - Playful Therapeutic Space…………………………….. 167
Creativity/Art Therapy – Conquering the Unknown…………………………….. 167
Creativity/Art Therapy - Mind-Body-Spirit Connection………………………… 168
Role of the Art Therapist…………………………………………………………….. 169
Observations…………………………………………………………………………. 170
CHAPTER VIIII: LITERATURE REVIEW – CRITICAL THINKING
Critical Thinking - A Historical Overview…………………………………………… 173
A Taxonomy……………………………………………………………………… 175
Characteristics ……………………………………………………………………. 176
How Does Academia Define CT? …………………...... 177
Where Has the Education of the CT Person Traditionally Taken Place?...... 178
In Search of the Critical Being……………………………………………………….. 180
A New Definition of the Critical Being……………………………………………… 182
Where Does the Future Education of the Critical Person Lie?...... 183
How Will the Teaching of the Critical Thinking Person Evolve?...... 185
How to Improve Learning …………………………………………………………… 186
Limitations…………………………………………………………………………… 186
Observations…………………………………………………………………………. 187
CHAPTER X: LITERATURE REVIEW – GROUP PROCESS
The Curative Factors of Group process……………………………………………… 191
CHAPTER XI: SYNTHESIS
Summary……………………………………………………………………………… 196
CHAPTER XII: REFERENCES
xii
References …………………………………………………………………………… 206
APPENDICES: METHODS AND PROCEDURES
Appendix A : The Guide ...... 244
How to View These Worskhops ...... 245
Critical Questions and Considerations ...... 246
Type of Group ...... 249
Group Process ...... 250
Screening Process ...... 250
Construction of the Group ...... 251
Goals and Objectives of Group Work ...... 252
Goals for the Facilitator ...... 256
Goals for Adolescent Participants ...... 257
The Benefits of Group Therapy ...... 258
Adolescents and Group Therapy ...... 259
Guidance Versus Counseling ...... 260
Appendix B : Role of the Counsellor ...... 262
Locating Spiritual Resources ...... 263
Leadership Skills ...... 263
Family, Cultural Values & Non-Verbal Cues ...... 265
Innate Worth of Human Beings ...... 265
The Right Learning Atmosphere ...... 266
Be Prepared, Organized and Flexible ...... 266
Monitoring Counter Productive Behaviours ...... 267
xiii
Stay Focused on Intent ...... 268
Adapting Counselling to Client Expectations ...... 268
Integration Versus Eclecticism ...... 269
Unifying Discourses ...... 270
Appendix C : Initial Intake Interview ...... 273
Appendix D : Evaluation Forms ...... 276
Intake information Form ...... 278
Intake Information Questionnaire - Adolescent ...... 279
Session Notes - Individual ...... 282
Session Notes - Group...... 283
Evaluation Form - Topic...... 284
Evaluation Form - Program...... 285
Evaluation Form – Facilitator ...... 286
Appendix E : List of Session Themes and Topics ...... 287
Appendix F : Suggested Sample Sessions ...... 300
Appendix G : Tips for Building a Lantern/Box Lantern Directions ...... 319
Appendix H : List of Psychoeducational Topics and Resources ...... 324
Appendix I : Honouring Worksheets ...... 335
Appendix J : Media Package ...... 338
Appendix K : List of Art Activities ...... 366
Appendix L : List of Creative Activities with Cross Cultural Links ...... 367
Appendix M : The Quaich ...... 368
Appendix N : Mandalas ...... 368
xiv
Appendix O : First Nations ...... 372
Appendix P : Medicine Wheel ...... 374
Appendix Q : History of Masks ...... 376
Appendix R : Mask-Making ...... 387
Appendix S : Art Reading/Material List (sample) ...... 389
Appendix T : Eating Disorder Resources List ...... 393
xv
LIST OF FIGURES
Figure 1 Stages of Change – Client ………………………………………………. 58
Figure 2 Stages of Change – Helper ……………………………………………… 59
xvi
CHAPTER I
Introduction
Stories are shaped by the narratives of our culture, form social connections to our world, conveying such things as gender, social roles, acceptable and unacceptable behaviour in a social context (Bruner, 1990). Narratives are also representational of lived experience, change with the telling (sometimes dramatically, sometimes incrementally), are selective and open to interpretation to fill some social purpose (Reissman, 1993) Given that they are evolutionary, they cannot be seen as exact replicas of events being described.
Narrative is experienced in the context of interaction with an imaginary (or real) audience
(Gilbert, 2002; Smythe & Murray, 2000).
Going on the premise that everything we do is in some way a self portrait, the process of telling this story contributes to an altered understanding of the story for the teller because the listener/audience becomes a collaborator in the evolving story (Gilbert,
2002). The goal is not to present an historical account of events, but to use these elements to understand and interpret a context for life. Narrative is not the truth but is filtered through a number of lenses where, with each lens, something is gained and something is lost (Gilbert).
Although the formulation of the current project was not developed for a specific research study, it does include a personal philosophical bias toward the interpretive/constructivist paradigm, and belief in multiple perspectives formed from a subjective frame of reference. The process did not consider this issue from an emancipatory paradigm viewpoint related to marginalized groups, participants involved
17
in the design and delivery of a study, a political stance, or a postpositive perspective that considered empirical data from a purely objective reality.
The process was, however, considered from cultural and narrative perspectives taking into account both the benefits and limitations of these approaches. I am interested in the critical periods where culture and individual psychology intersect and how that plays out in the development of pathology. As Pipher (1994) suggested adolescence is a fascinating study because it is “…… one of these extraordinary times that is marked by great internal development and massive cultural indoctrination.” (p. 13).
In this project, I act as a form of cultural guide, a conduit of information and a co- constructor of the narrative. Both the content and perspective are selective and biased. I was raised as a European female, inside a Scottish clan culture, and my formative era was the Sixties. As a result of my formal education and working life experiences, I have made choices about what to report, which parts to pursue, and how to interpret other’s statements. As Reissman (1993) stated “…… the investigator cannot help but influence the story, because simply by listening, they change the narrative ….” (p. 228). It is hoped, however, that a more objective account has been generated by being empathic, showing unconditional positive regard, and being willing to consider that someone else’s perspective may be as legitimate as my own.
Jung (1968) wrote about the role of religion, spirituality and meaning that speaks of an inner voice that at some point, calls to everyone across race, culture or nationality.
This inner quest revolves around the fundamental question of “What is my life all about?” or “Why am I here?” Individuals may start out with a rather simplistic spiritual outlook but life has a way of demanding more with the result that the search for
18
spirituality often becomes a lifelong journey. How we go about answering the meaning of these questions for ourselves can be a tremendous source of personal energy, fulfillment and spiritedness.
Otto (1957) in The idea of the Holy suggested that strictly speaking spirituality cannot be taught but it can be “… evoked, awakened in the mind; as everything that comes ‘of the Spirit’ must be awakened.” (p. 7). He also suggested that a numinous feeling could spread and be transmitted from mind to mind (even in small doses) by fine tuning the mood and tone of our kindred feelings so that the ‘spirit of the heart’ is stirred and receptive. He talked about a quale with a potentiality of its own, capable of becoming because “…Man has this in him and is capable of realizing it through training…” (p.
175). He likened the feeling to anamnesis which is “… a recollection of something that was a familiar possession in the obscurity of feeling even before the moment of insight.”
(p. 196). He also made the analogy of a powerful force manifested in the beauty and the sublime of the creative.
While Otto (1957) felt that it was one thing to believe in a reality beyond the senses it was something else to experience the spirit that dictates the voice of conscience and consciousness as an operative reality, intervening in the phenomenological world. He described experiences that could be directly encountered in particular occurrences and events, self-revealed in persons, displayed in actions or in a word that “besides an inner revelation from the Spirit, could also manifest as an outward revelation of “the holy” could stand palpably self-revealed …” (p. 142).
As I look back over the last ten years of higher education studies at a number of
Canadian Universities (many of them related to counseling) what surprises me is that few
19
of my courses or workshops dealt with spirituality directly, offered specific spiritual educational resources or asked me to consider the value of spirituality in my own life.
Yet, it seems to me that incorporating spiritual and creative elements into a therapeutic plan is fundamental to living a healthy life and critical to considering new ways of being.
Paul Tillich (1948) suggested that one goal in life should be to seek a better match between our internal calling and ordering of truth, and our external actions by probing the ground of our internal teacher, examining what we have learned to be true, and clarifying this inner sense of meaning-making. This view suggests that we have a responsibility to translate and make transparent our truth by making our beliefs and values open to scrutiny. Incorporating my own spiritual journey to be the best person I can be with my vision for professional practice seems a natural outcome of my own growth at this time in my life.
Not wanting to churn out another academic paper that would lie at the back of my closet gathering dust, I have chosen to interweave into the fabric of this endeavour some of my own journey from conscious recognition to conscious examination which has helped convince me that insights, critical consciousness, creativity and the grace of the spirit are essential tools in this transformation. Showing how these coalesce to form theoretical constructs and systems of therapy will clarify my personal theoretical paradigm, create a context for what it is that draws me to practice the way I do, and help the reader understand my intentions in this project more fully.
This project includes the following:
A Rationale, philosophy and mandate for the program;
The role of theory in the overall process;
20
The role of spirituality, critical thinking and creativity and how they integrate;
Details of the group process and how it works;
Details of the creative process and how it integrates with the group process;
A list of psychoeducational topics and resources for use in sessions;
A detailed list of creative activities for use with various themes;
A template for sample sessions and session formats;
Reference lists of educational videos, slides and readings;
Evaluation forms to assess the effectiveness of the program, group process,
creative process, facilitator, format and content.
One of the main goals with this project is to examine the literature related to the areas of self, spirituality, eating disorders, art therapy, creativity, critical consciousness and groups to identify themes and topics that will form the basis upon which to base a more holisitic therapeutic approach to group interventions. The premise is based on taking a
Bio-Psycho-Social model of interaction and replacing it with a Bio-Psycho-Social-
Spiritual model that embraces a more holistic approach. A second goal of this project is to provide a guide for facilitators that integrates spirituality, psychoeducation and art therapy components under one nucleus using consciousness raising, creativity and art history (described more fully in The Guide - Appendix A).
Chapter II discusses theoretical foundations, Chapter III discusses the ethic of care for vulnerable populations. Chapters IV through X provide literature reviews on spirituality, eating disorders, critical thinking, creativity, art therapy, self and group process (Chapters
IV through X). Methods and procedures are discussed in Appendix A including an overview of the issues that need to be considered and the structure and function of the
21
group process to allow a facilitator to develop their own group and/or to run a group based on the material presented. Also included is the role of the counsellor (Appendix B), initial intake interview (Appendix C), and evaluation forms (Appendix D. Thematic topic areas identified in the spiritual and eating disorder literature reviews form the foundation for the workshops in Appendix E. Sample sessions are described in Appendix F.
A third component of this project, the complete resource manual (500 pages), is beyond the scope of this project. However, a number of samples from the psychoeducational and art therapy resources lists are included in Appendices G through
T. It is expected that a facilitator would want to put together their own complete resource kit based on the suggestions put forward in the list of psychoeducational resources suggested in Appendix H.
The manual should contain a series of resources that would be used by the facilitator, and also a number of simplified handouts related to the same resources for each participant geared towards an adolescents’ level of understanding. For instance, examples of the spiritual worksheets (Appendix I), the complete media package (Appendix J) and tips for building a lantern (Appendix G). These examples give the reader a sense of the types of resources that need to be included.
The structure of sessions is such that each topic area stands alone, yet can be used to build on the one before. The workshops are also adaptable and flexible enough for practitioners to integrate their own ideas or replace segments that may not fit for their situation. In Appendix H there is a comprehensive list of suggested psychoeducational resources, samples of honouring worksheets (Appendix I), a sample of a comprehensive media package (Appendix J), a list of art activities (Appendix K), samples of art therapy
22
components with historical and/or cross cultural links (Appendix L through R). Also included is a resource list of eating disorder web sites (Appendix S) and a list of resources carried at the Eating Disorder Resource Centre (Appendix T).
It is hoped that this project will spark debate and discussion for individuals seeking greater understanding about how the spiritual person might be educated or treated therapeutically in the future. Hopefully, what will become clear to the reader is that the intention in this process is not to replace individuals’ faith traditions but to embrace them in a more holistic manner. I am also reminded that no story ever really ends. That there is always something else comes after. As Janie Rhyne (2001) would say “I live in a world of et cetera …….” (p. 116)!
23
CHAPTER I
Introduction to the Guide
This chapter offers an introduction to the guide for a group program, an encapsulation of the problem, and a rationale for why this approach might be more beneficial for individuals suffering from an eating disorder. An overview of the purpose and structure of the guide is also included plus an explanation of a philosophical shift away from the more traditional methods of disseminating information.
This guide is based on the premise that individuals suffering from an eating disorder are disconnected from themselves, the world around them and their spiritual selves
(Lelwica, 1999; Manley, Smye & Srikameswaran, 2001). Eating disordered adolescents often display an impoverished creativity and usually function on a highly developed, heavily ingrained distorted logic that is harmful to themselves and others. Although there are a host of psychoeducational workshops that deal very well with myriad relevant topics around eating disorders, self-esteem, the role of the media, stages of change, addiction, body image and nutrition, there are few that connect these to the spiritual realm of adolescents’ lives (Lelwica, 1999). Fewer still incorporate an art therapy or experiential approach.
Offering a spiritual approach to therapeutic intervention can provide a number of ways that adolescents with eating disorders can understand their connection to a larger universe. Inherent in this belief is that the spiritual background, wishes and needs of a person are as important as physical health, psychological functioning or social support. A spiritual approach may be critical to addressing the whole individual within a more holistic care plan that builds on strengths, develops a larger sense of self, and a more
24
spacious mind. Emphasizing spiritual nurturing of mind, body and spirit using the development of critical consciousness and creativity in a group process can also encourage individuals to connect or reconnect with family, friends and community
(Walsh, 1990a, 1990b, 1999a, 1999b, 2000; Walsh & Vaughan, 1993).
Problem Statement
Eating disorders are illnesses that are multi-faceted and multi-layered which often begin during adolescence (Manley, Rickson & Standeven, 2000). The etiology stems from the interplay between biological, psychological and social elements that incorporate a variety of risk factors. These various elements include cultural emphasis on thinness, perfectionism, trauma, issues around competitiveness and control, and heightened concerns around appearance and body shape (Manley, Rickson & Standeven).
Adolescents struggling with these disorders also often experience cognitive distortions, self-punishing thoughts including self-mutilation, suicide ideation and suicide attempts brought on by profound anguish and despair (Manley & Leichner, 2003). In working with this population as a clinical counsellor and art therapist, a recurring theme that often crops up is their sense of loss and disappointment with the significant individuals in their lives. Some have an aversion to the more traditional therapies, and a number of them display a pervasive disillusionment with the current society. All of them seem to struggle with their sense of self, issues around self-esteem and finding the essence of who they are.
In this approach, the assessment and management of the younger population with eating disorders differs from that of adults because of the developmental process that is occurring at this time (Lask & Bryant-Waugh, 1995). Lelwica (1999) suggested that there
25
are few psychoeducational workshops that connect relevant topics to the spiritual realm of adolescents’ lives. Adolescents struggling with an eating disorder are often dealing with issues around illness, death and dying, grief and loss, guilt or resentment because significant people in their lives have let them down. These teenagers may have unresolved issues around the question “Why me?”, therefore, connecting these topics to spiritual and creative tools and strategies may be one way to explore a multiplicity of life’s issues more fully.
Also, health care professionals have an ethical obligation to help people they serve address their spiritual needs and concerns by incorporating a spiritual component into a treatment plan (especially where individuals are feeling alienated from the people in their lives and their social world). Particularly, they should help individuals without established ties to a faith community locate spiritual resources that meet their needs.
Rationale
Although the term spirituality is ubiquitous, and a great deal of theoretical literature has been written, preliminary evidence suggests that the concept of spirituality has a different meaning for different people depending on an individual’s faith community, belief system or values. Spirituality is no longer wedded to religion in the same way that it once was but it is still an important part of individuals’ lives (Erricker, 2002). Many government and private health care agencies are reluctant to include spiritually focused support in their arsenal of psychoeducational or therapeutic options believing this to be outside their mandate and perhaps an infringement on an individual’s religious beliefs or faith (Erricker).
26
From a therapeutic perspective, research evidence links spirituality to improved health outcomes for patients, caregivers, and health care professionals (Roff & Parker,
2003). A mature understanding of human health recognizes that the spiritual aspect of existence should be acknowledged and spiritual resources mobilized. The purpose, not to force a specific spiritual position or belief on anyone, but to offer spiritual support that respects where the person is at in their spiritual journey.
Armstrong and Armstrong (2003) suggested that increased focus on technology in the last century has resulted in a deep separation between the quest for healing and the pursuit of spirituality but that this approach is disappearing. The World Health
Organization (WHO; as cited in Armstrong & Armstrong) has suggested that, until recently, health professions have largely followed a medical model which seeks to treat patients by focusing on medicines and surgery, and gives less importance to beliefs and faith. The WHO now concludes that this reductionistic or mechanistic view of patients is unsatisfactory suggesting that it is no longer reasonable to compartmentalize human experience and health into separate dimensions (WHO; as cited in Armstrong &
Armstrong).
It is argued here that dismissing the spiritual dimension in an individual’s life may diminish the sense of purpose that individuals need to live happy and healthy lives.
Conversely, as Gambone (2003) suggested, a doze of good spirit may contribute toward making us better people and more able to cope with life’s trials and tribulations. In view of the centrality of spiritual experience in the lives of so many people who are dealing with major health crises, and the growing evidence that individuals derive support from their spiritual beliefs and practices, the key question would appear to be – How to
27
incorporate spiritual resources into individual lives that best meet their needs?
(McIllmurray et al, 2003).
The Purpose of Spiritually Focused Workshops
The purpose of these group workshops is to cultivate a preferred identity and work towards developing a personal spirituality based, not on how to avoid hardship and pain, but how to live with meaning, joy, gratitude and awe while acknowledging the irrevocable claim that sorrow makes on our lives. The idea being to listen without having an agenda, opening up to sorrow, finding connection in loss, attending to the present, resting with uncertainty, accepting fear, tending to relationship with aloneness and believing that there is always something that can be sustaining (Lelwica, 1999).
The workshops also examine how tragedies that occur in our lives may be viewed as spiritual journeys that can be looked at as sources of strength. Each topic area incorporates a critical thinking piece, inspirational or motivational elements, a creative technique or process with historical lineage, personal art making and shared experiential components. The process also includes information from various sources on dealing with the topic, ways to incorporate the learning, and further suggested readings. The intent is to plant the seeds for developing the individual as a critical being.
These are stand alone workshops that can be used independently of each other but the raison d’etre is to function as a series - one topic building on the content of the one before. With minor alterations for age and development this series could be used in a number of agency settings by any individual or group looking to incorporate a spiritual component into learning that appeals to all denominations and belief systems without affiliation to any specific religious group.
28
The Structure of the Guide
A great deal of consideration has been given to the best way to combine the development of spirituality, creativity and critical consciousness into a psychoeducational/art therapy group process. This particular series has been developed as a “how to” guide for care professionals who are charged with the task of providing counseling/psychoeducational/art therapy/experiential workshops in a group format for adolescents (13 – 19 year olds) diagnosed with an eating disorder. The material can be used as a template to run a group or be used to develop one based on this model.
The term eating disorders will be used to describe the DSM-IV categories Anorexia
Nervosa, Bulimia Nervosa and Compulsive Eating Disorders (American Psychiatric
Association, 1994). The workshops are structured to incorporate spiritual components into therapeutic work in a more directed way as a Bio-Psycho-Social-Spiritual model for interaction. The word adolescent has little meaning in some cultures so the term teenager will also be used to describe this age group (13 to 19 years of age).
Although the workshops incorporate understanding of the academic literature in the areas of spirituality, critical thinking, creativity, art therapy, eating disorders and group processes, this project is not to be considered a research study. Any of these major topic areas could potentially encompass a lifetime’s work and is beyond the scope of this project given time and length of paper restrictions.
Most of the research for this project was found using Psych Info, Academic Search
Premier, Sociological Abstracts, ERIC and the worldwide sites accessed through the
University of British Columbia, University of Calgary and the University of Lethbridge.
Particularly useful was the University of British Columbia McMillan Library housed at
29
Children’s and Women’s Hospital and the Eating Disorders Resource Centre at Children
& Women’s Hospital in Vancouver. Literature reviews in the areas of spirituality, eating disorders, art therapy, critical thinking, creativity, self and group process were done to establish critical themes, topic areas and psychoeducational components.
Unfortunately, there are few psychoeducational literature articles that connect relevant topics to the spiritual realm of adolescents’ lives through the creative and experiential process (Lelwica, 1999). Literature linking spirituality, eating disorders, art therapy, critical thinking, creativity and group process using an art therapy/art history approach were unable to be found. The genus for these workshops evolved out of my own experience of individual and group counseling using cognitive, behavioural and art therapy components, and through providing group psychoeducational workshops on many different topics to this population.
These sources were supplemented by my own knowledge and understanding while studying at Emily Carr Centre for Fine Arts, Kwantlen University Psychology and Fine
Arts Studio work, University of British Columbia degree programs in Philosophy,
Psychology and Fine Arts Studio work, University of British Columbia Department of
Education Post-Graduate certificate in Psychology and Guidance Counseling and
Vancouver Art Therapy Institute Post Graduate Art Therapy program.
A Shift in Focus and Intention
The intention with this group program is to move away from more traditional methods of disseminating psychoeducational information for the mind as passive listeners, towards a learning while creating, participating, connecting approach. The process is also geared to explore the role of art and art-making as food for the soul and to
30
examine the art process as a powerful source of healing and transformation. A great deal of consideration has also been given to the how, when, where, and to what degree these various modalities should be introduced into the process so that it does not affect the cohesion of the group and capitalizes on building a studio atmosphere as sacred space.
In the following chapter insight is provided on how personal issues are expressed and how art therapy, creativity and critical consciousness might be integrated into articulating a spiritual philosophy into one’s own life. This information is important to provide a context for the reader to understand some of the biases that motivated the writer to incorporate spiritual elements into the formulation of this group program.
31
CHAPTER I
In this section the personal philosophical and pedagogical beliefs and values related to how life is viewed by the writer are discussed. Particularly, there is insight provided on personal goals related to living the optimistic life and describing the human journey as this dynamic striving “… not as a being but as a becoming” from a spiritual perspective
(Mosak, 2000, p. 56).
About the Author
Looking back over my own life, I realize that I have sometimes struggled with the ability to maintain a sense of inner abundance even although I have many material gifts.
Like many people, I have often wondered if this material world is all that there is.
Through this self-reflective process, I have come to recognize my own power but acknowledge faith in a higher one. Developing a positive attitude toward my own aging, and connecting that with my spiritual beliefs, allows me to live a richer and fuller life.
On a personal level, discovering my spiritedness includes taking time for personal reflection about how my own beliefs and values bring meaning and purpose to my life.
Cultivating my own spirit means finding ways of sharing with others my talents, gifts and passions. Being spirited also involves seeking better balance between self-care, quiet time, relationships, work and citizenship. Sometimes spirituality means slowing down in order to re-energize myself or taking the time to go down new paths that inspire me to make a genuine contribution to the larger society. Other times being spirited means living with integrity and authenticity and being involved in activities that demonstrate compassion and caring for the society I live in.
32
It has also become clear to me that I am philosophically and pedagogically drawn to forms of teaching and that there is a link between spirituality, faith and teaching. Making meaning out of lived experience by developing a set of beliefs and values that organize and order interactions, and forming a corresponding set of pedagogical beliefs helps individuals make judgements about which actions are justifiable, right or wrong, and which are arbitrary. When I ask myself why I hold the beliefs I do, or why I order my interactions the way I do, I turn inward to check on an emotional level about what feels right! Sometimes I seek more objective input from others, but ultimately I rely on my inner voice to resolve uncertainties.
In my professional practice, I am moving towards a more intermodal approach to counseling that incorporates what Miller and Milliken (2002) refer to as “…… a more integrated repertoire of responses that embody meaning and knowledge…” (p. 82). I want to welcome the unknown into the therapeutic space, become more comfortable with a not knowing stance, enjoy ambiguity and expand the role of the senses to develop a more curious approach to my work and by extension foster these in my clients.
I need to be an optimist and give meaning to this life by instilling in other’s positive energy, and hope that humanity is not losing ground to a rising tide of savagery.
However, how I think of myself is probably at the core of understanding who I am and how I function. I agree with Aristotle who suggested that the unexamined life is not worth living, and with Carl Jung who suggested that the journey inward toward our inner teacher and greater pedagogical certainty is inherently spiritual.
33
Personal Philosophy - Becoming
My personal philosophy for living involves the Dasien notion of mindfulness based on a kind of Buddhist philosophy and meta-practice. While not a Buddhist, I like to practice meditation, living with intention and trying to live with deliberation and thought on a daily basis to develop a larger sense of self and a more spacious mind (Miller &
Cook-Greuter, 2000). For me, a spiritual life extends beyond inner action to include service to my community that honours mindfully my connection to a larger society.
Being spiritual is not so much about doing but about being or becoming. Like Koepfer
(2000) my way of being in the world embraces the interconnectedness of life where service to my community is not so much a choice but a responsibility.
From a Taoist perspective, the art therapy process is analogous to the movement of
Heaven’s energy via the human imagination, through the body and into the earthy substance of the page. Similar to the union of essence (jing – the essential components of the physical body); energy (chi – the energy that flows through all bodies); and the spirit
(shen – the mind or spirit of the Tao (Miller & Cook-Greuter, 2000). As a practicing artist who has studied the formal aspects of art and used the art process in my own life, my approach to art therapy as a profession is similar to Landgarten (2001) who speaks for me when she suggested “Art is something that I have pursued all of my life and I continue to ponder its meaning.” (p. 82). At this stage in my life, I feel driven to incorporate the Arts more fully into my personal life and professional practice.
An Optimist at Heart
As an optimist at heart, I like to think in terms of human striving that has been passed down from Plato’s ideas on potential forms, which influenced Carl Jung’s notions of
34
ideas and images, and Alfred Adler’s understanding of the self-actualization process
(Arlow, 2000; Douglas, 2000; Kriz, 1999). Dwelling on a growth model of personality rather than a sickness model with goals of prevention rather than cure is a more hopeful view of human nature. This view is much more uplifting to know that mistakes are never carved in stone, and that what is learned can be unlearned, replaced or improved upon.
My intellectual and personal growth is geared towards building strong personal, working and therapeutic alliances in an atmosphere of warmth and respect. I need to remind myself that other people’s perspectives are as legitimate as my own and remain open to new ways of thinking and doing things. My intention is to incorporate who I am into a coherent, sound and ethical practice that balances work and the other parts of my life. The following Chapter expands on the theoretical understanding used in this project on human nature, healing, pathology, development and growth.
35
CHAPTER II
Theoretical Foundations
The following chapter provides insight and understanding on how the writer views human nature and the psyche, development and growth, seeds of pathology and general goals of therapy. This information is important because it forms the skeleton upon which therapeutic interventions are based for running a spiritually based group program. How the concept of an effective working alliance as well as how faith, trust and rapport are developed in relationship provides the reader with insight on how these elements are built into the group process.
Creative, Self-Determined Growth Across the Lifespan
I lean strongly towards the humanistic/psychodynamic/phenomenological approaches to theory based on relational/narrative principles and endorse self-sustaining behaviours, growth and acquiring knowledge, and skill competency. Memory, emotions, behaviours and conscious and unconscious mind are in the service of the individual as an indivisible, unified whole (Mosak, 2000). Individuals react to the environment and mind and body are interrelated in functioning. The individual operates on a subjective core of experience.
Biology is influenced by experience, and individual experience determines reality.
Environment and hereditary interact to produce personality or personality traits that an individual uses (or not) to advance towards personal goals (Ansbacher, 1990, 1997;
Arlow, 2000; Watts, 1996). I lean towards the Jungian concept of the reality of the psyche described as “a combination of spirit, soul and idea …” (Douglas, 2000, p. 99). Psychic reality is viewed as the combined inner processes of the conscious and unconscious mind
36
that includes an expanded spiritual connection emphasizing meaning-making through myth and symbols.
Human Nature
Humans generally strive for close personal relationships and are heavily influenced by social situations and group interactions. Cognitively how we perceive and interpret our world will greatly influence how that is manifested (Corsini & Wedding, 2000).
Human beings as creative and self-determined decision-makers generally chose to self- actualize. As choosers they shape their own internal and external environments which are influenced by lifestyle, assessment of environmental situations and the kind of rewards that an individual might learn to expect. Individuals grow and change over the lifespan in developmental stages or as a result of crisis (similar to Erik Erikson’s idea of life cycles) and happiness and success are largely related to social connectedness (Myers, 1995).
Family of origin and culture are primary social environments that contribute to an individual’s personality through their perceptions of their struggle to find a place of significance. Although intrapsychic problems from the past are important, I am more interested in current dysfunctional behaviour. Past childhood experiences may not necessarily determine behaviour but interpretation of events is crucial (Mosak, 2000).
Physical, psychological, social and spiritual changes are experienced by individuals facing many of life’s hurdles. Inherent in this view is that spiritual needs are as important as medical ones.
Seeds of Pathology
Individuals act according to how they see themselves, how they think things should be, their view of the world, and what it demands of them. People also struggle with
37
ethical convictions of right and wrong (Douglas). Interconnectedness and how individuals relate and cooperate with each other is also important as well as how valued they feel in their assigned roles, how they understand the nature of the universe, and their belief in the existence of some higher power. Managing the relationship between “I” as the actor in life, and “I” as the motivator and decision maker is on-going (Ansbacher,
1990, 1997; Mosak, 2000: Watts, 1996).
Conflicts are conflicts of life, and sources of pathology stem from inferiority because of distorted perceptions often fomented by media hype and unattainable societal and political pressures (Corsini & Wedding, 2000). Feelings of inferiority over social status, sexual roles, inadequate physical endowment, sexual weakness or discrimination based on social comparison also have a role to play in neuroses (Cooley, 1922; Festinger, 1954;
Mead, 1930; Sullivan, 1953; as cited in Burkhardt, 1984). Most individuals need to belong, feel connected to others, and contribute to the greater good of the community to be truly healthy (Mosak, 2000).
Although my view may go against the grain of current psychological thinking, I am no longer as convinced that personality is primarily formed in the first five years of life, that all neuroses stem from biological instincts, or that most neurotic symptoms are rooted in childhood (Ansbacher, 1990, 1997; Mosak, 2000: Watts, 1996). I am also not convinced of the degree that sexual etiology, biological or genetic components and past memories are motivating factors that cause neuroses in current mental thoughts, behaviours and emotions although they may play a role (Arlow, 2000).
Maturational processes go across the lifespan and humans often struggle to maintain homeostasis (a two steps forward, one step back kind of motion similar to what Jung
38
refers to as enantiodromia), (Douglas, 2000). Individuals experience themselves in the throes of conflict and unable to move, when in reality they create these antagonistic feelings, ideas and values because they are sometimes unwilling to move in the direction of solving their own problems (Osborn, 2001). Social issues, economic hardship, deprivation, inadequate or failed attempts at learning, faulty perceptions of faulty values as a result of distorted interpretation of events, trauma from the grief and loss associated with life transitions such as marriage, divorce, retirement, death and loss are more likely to be seeds of pathology that lead to neuroses (Arlow, 2000; Corsini & Wedding, 2000;
Knill, 1995, 2001).
Working Alliance
Being in language with a client implies a less hierarchical, more egalitarian, friendly, respectful and human experience. Although the Rogerian principles of empathy, positive regard and congruence would be used, a more directive approach to psychotherapy would be used where ideas, opinions and questions are included as a more cooperative educational enterprise (Anderson, 2001; Ansbacher, 1990; Mosak, 2000). Without a strong working alliance built on faith and trust between client and therapist, belief in the intervention of specific modalities would be doomed to failure (Horvath & Symonds,
2001). Connecting with the client is paramount for everything else to fall into place.
Psychological or social distance between myself and a client would be viewed as a personal failure and potentially harmful to building a trusting alliance that is of paramount importance for self-revelation and change to occur. I would like to function as a role model for the client as a way of being in the world that acknowledges and accepts
39
human frailties and imperfections (Ansbacher, 1990; Mosak, 2000; Osborn, 2001; Watts,
1996).
For some clients, counseling may be the only place where they are validated by another caring and empathic individual which can generate discussion on what is important or missing in their lives (Ishiyama, 1995). A strong therapeutic relationship is critical in supporting clients and helping them face their fears or ambivalent feelings. The helping relationship is particularly important in creating the ambience and atmosphere of a place where clients can feel safe, respected and comfortable enough to freely explore various personal and societal issues and validation themes (Ishiyama). Finding meaning in their experiences is helpful in viewing transitions as opportunities for positive growth that leads to an expanded worldview with greater cognitive, emotional, behavioural and spiritual repertoires (Ishiyama).
General Goals of Therapy
The goals of therapy are to foster self-realization manifested in better personal relationships and collaborative goals. The focus is on encouraging individuals to have faith in themselves, trust their instincts, and to find the capacity to love themselves and others more deeply (Mosak, 2000). Insight is necessary for change to occur but there is a strong distinction to be made between intellectual insight (the desire to play the game) and emotional insight (cognitive understanding translated into action) (Ansbacher, 1990;
Watts, 1996). The intent would be to reorient a client to more realistic goals of life away from unattainable goals of security, mistaken perceptions of life and its demands. Also to separate fact from fiction, and replace feelings of low self-worth with greater self-esteem, sense of accomplishment, and self-awareness (Arlow, 2000).
40
Focus would be on developing motivation modification (second order change) because changing behaviour would not be considered a success but changing the goals, concepts and notions that motivate behaviour would be. Art therapy, narrative progress notes, motivational interviewing and practiced verbal skills would be used to emphasize
“… purpose not cause, movement rather than description and use rather than possession”
(Mosak, 2000, p. 77-99).
I favour art therapy, role play, acting “as if”, talking to an empty chair, magical questions or push button techniques to dislodge faulty beliefs and values and promote new learning situations. Using humour, anecdotes, biography, illustrating fables, fantasies, prose, poetry, art history, education, and guided imagery to create the “Aha!” experience would serve as indicators for further treatment (Mosak, 2000). I would reject fixed symbolism and use Jung’s expanded view of the psyche and his understanding of symbol formation to try to understand both the dreamer and the dream (Douglas, 2000).
Faith in the belief of individuals as creative, self-determined individuals who choose to self-actualize across the lifespan provides the motivation and conviction (for writer/reader, helper/helpee) that this group approach can work. It is an optimistic view that focuses on completion, self-realization, competence and mastery. The idea of showing courage to face the unknown, to tilt at windmills sometimes, and take risks in spite of inadequacies. Satisfaction and happiness is determined by whether an individual approaches life as an optimist or pessimist where one can either relish the opportunity of taking chances, or hang back, become discouraged, and refuse to engage in life’s challenges (Mosak, 2000).
41
Using this perspective related to how the world works and sources of neuroses suggests that biology, personality, experiences, belief systems and values, and socio- political contexts play a role in the treatment process. This optimistic view of human nature is more palatable and relevant a framework within which to run this type of group program. Therapeutic interventions are creatively and socially constructed yet simple, practical, goal-oriented, and relatively inexpensive. Also acknowledged in this approach is a cultural context which will be discussed in the next chapter.
42
CHAPTER II
Theoretical Foundation
A Cultural Perspective for Therapeutic Counseling
The topics of multicultural counseling, internalized culture and worldview are discussed in this chapter. A definition of both these terms is provided which highlights the differences between these two notions. Understanding of these concepts is critical for being able to connect with each individual, understanding how beliefs and values develop within a cultural context over time, and how individuals articulate their beliefs and values in their daily lives.
Arthur and Stewart (2001) proposed that the field of therapeutic counseling in the
West has been dominated by Euro-North American understanding and bias of how healthy humans function. Pedersen (1995) suggested that Western style mental health interventions are often inappropriate, too expensive, and too dependent on technology.
Daya (2000) found high rates of attrition and low use of mental health services by other culturally diverse groups because of a lack faith in the efficacy of Western therapeutic interventions.
Some research has suggested a psychological chasm may exist between Eastern and
Western philosophies. Other research has shown a lack of common ground among diverse groups concerning health/illness, loci of control/responsibility, spirituality and faith in the efficacy of Western therapeutic interventions (Arthur & Stewart; Ho, 1995;
Nelson-Jones, 2002). Therefore, finding new and expanded ways to explore individualism/collectivism, autonomy/interconnectedness, objectivity/symbolism,
43
spirituality, human nature, and how the world works can help define and bridge differences in the goals of healing.
As a Scot and as a Canadian, I acknowledge that there is embedded in my training as a counseling psychologist, art therapist, artist and educator, a Eurocentric indoctrination which carries ingrained biases, stereotypes, beliefs, values and behaviours in my perspective to health and illness. I can also envision Western psychological counseling becoming an anachronism in my lifetime unless it is willing to adapt to a new global reality, find some common ground, and embrace cultural diversity as a central force in psychological processes (Pedersen, 1995).
One of the overarching premises on which this project is based is the universalistic belief that to some extent all mental health therapeutic endeavours are multicultural because helping originates in a cultural context that assumes a common humanity and cultural diversity (Dana, 1998; Daya, 2001; Ho, 1995; MacDougall & Arthur, 2001;
Pedersen, 1995; Ramsey, 1997). Multiculturalism is also a concept of human nature that embraces some values from a dominant culture, retaining values from one’s own culture
(whatever that might be), and incorporating cultures of others that individuals get to know (Arthur & Stewart, 2001; Esses & Gardner, 1996).
The cultural term used here encompasses attitudes, values, beliefs and behaviours as well as demographics, status, affiliation and ethnographic variables. This term also incorporates the understanding that people have of their universe (social, physical, psychological and spiritual) including their behaviour in that universe (Daya, 2001; Ho,
1995). When culture is broadly defined in this way each person holds a unique cultural
44
composition which means that all forms of helping relationships are defined as multicultural.
Internalized Culture and Worldview
A cultural perspective is a learned behaviour that encompasses rules and norms passed down through heritage and traditions that acknowledge a process of socialization that makes the experience unique (Berry, 1997; Merali, 1998; Pedersen, 1995). An individual’s culture serves as a guide in an individual’s interpretation of events, colours their expectations and actions in that environment, and includes cultural practices, customs, values and perceptions of themselves and others. Cognitively how we internalize our worldview related to the self and others will greatly influence how that is manifested (Dana, 1998; Trevino, 1996).
Internalized culture is a psychological construct that is instrumental in development of self-identity and worldview based on cultural boundaries and orientation in cross- cultural interactions (Ho, 1995; Trevino, 1996). Worldview addresses explicitly both individual identity (self-concept) and group identity (both within groups and between groups) that deals with the nature of cultural heritage (Dana, 1998; Pedersen, 1995).
Ibrahim (1991) suggested that worldview is a culturally based lens through which people interpret their world stemming from the socialization process.
Worldview is more global and encompassing than cultural identity and is considered the foundation for one’s perceptions of beliefs and values (Greiger & Ponterotto, 1995;
Sue & Sue, 1999). In a society like Canada that is seen as multicultural, understanding internalized culture and world view is not only critical for understanding racial and ethnic
45
identity, but also those other aspects of self (ideological, gender, sexual, self-concept) that contribute to a fully functioning human being (McDougall & Arthur, 2001).
Worldview becomes critically important when we consider an individual’s deeply held beliefs, values and central core convictions because we are discussing how individuals believe they ought to behave, how they think their societies want them to be, and the value or worth they place on their end state of existence for how they think they ought to live. Beliefs can be consciously conceived or unconsciously held values and principles which are often ingrained and difficult to change because they are based on how one continues to experience the world and how one internalizes or understands that experience (Sue & Sue, 1999). For instance, research evidence shows that anorexia nervosa and bulimia nervosa are usually highly valued by the sufferer (Serpell,
Neiderman, Haworth, Emmanuelli & Lask, 2003).
In current Westernized societies with their emphasis on beauty, eliminating fat and cultivating fitness, or where thinness equates to health, strength and goodness, it is easy to see how adolescents can be caught in an emotional minefield that is difficult to maneuver. Lelwica (1999) suggested that contemporary North American cultural and social values and religious legacies produce feelings of emptiness and dissatisfaction.
These notions become even more complicated because individuals need food as a basic necessity to live, and all human cultures have developed ritualistic eating behaviours that have been passed down over centuries as symbols of devotion, love and affection. Also ingrained in spiritual and religious traditions from around the world are moral judgements attached to certain kinds of foods and eating behaviours (Lelwica, 1999; Pipher, 1994).
46
Ishiyama (1995a, 1995b) accorded worldview central importance in generic counseling and suggested that transcending one’s internalized culture through self- awareness and self-understanding is an essential component in counseling competency, the basis of competent practice, and the most relevant construct for both therapist and client. Ho (1995) suggested that when individuals understand their own cultural heritage and its associated worldview, it avoids cultural encapsulation, a monocultural perspective and helps to sensitize them against stereotyping or overgeneralizing by encouraging consideration of how biases infiltrate thinking (Ho, 1995; Pedersen, 1996).
By adopting a comparative frame of mind that liberates people from cultural encapsulation, worldview facilitates psychological decentering (Ho, 1995). Worldview also helps individuals develop understanding of a wide array of similarities and differences in society’s norms that govern interpersonal behaviour, as well as many social system variables that contribute to a client’s worldview (Arthur & Stewart, 2001).
MacDougall and Arthur (2001) proposed that self-awareness as racial beings and understanding how history, socialization, politics and socio-economic conditions continue to impact individuals is the basis of competent practice.
Sue and Sue (1999) suggested that effective therapeutic interactions hinge on the ability of counsellors to assess a client’s worldview related to individual uniqueness, group experiences and human universality. Therefore, it is important for the facilitator to consider questions such as – What does this individual care about? What matters to them?
What does this individual have genuine, spontaneous, unrehearsed energy for? What is at the core of this person’s being and belief system? – in an attempt to understand the motivating factors in that individual’s life. To develop a more global awareness it is also
47
necessary to stimulate personally relevant and reflective questions that individuals can ask themselves to develop a habit of functioning that activates their own consciousness.
Ho (1995) proposed that “…all Whites are racist whether knowingly or unknowingly…..” (p. 113). Therefore, in deference to that possibility, it is a major goal and commitment of this group project to offer ways to transcend internalized culture and egocentrism in an attempt to articulate a more spiritually inclusive approach to life where value judgements and moral reasoning are no longer anchored to any one culture
(LaFramboise et al; as cited in Ho, 1995).
This information is relevant to running a spiritually based group program because the facilitator needs to understand the differences between internalized culture and worldview to be sensitive to each individuals view of their world, ensure that the group process is inclusive, and that the risks of conflicting with family or cultural beliefs and values are minimized or avoided altogether.
The chapter suggested that there are global pressures being put on the counseling profession to incorporate the tenets of multicultural philosophy into culturally responsive counseling that more appropriately meets the needs of a diverse, evolving Canadian
Society (Arthur & Stewart, 2001; Esses & Gardner, 1996). Being trained in cognitive, behavioural, and expressive therapies, and knowing culturally appropriate humanistic and spiritual healing practices of East and West, means that one can practice more competently, fairly, caringly and ethically without discrimination. The following chapter expands on many of the ethical issues needing to be overcome when working with this vulnerable population.
48
CHAPTER III
Ethics
This chapter discusses a number of ethical issues that need to be considered when dealing with adolescents suffering from an eating disorder. Adolescents are considered a vulnerable population and given that the law is somewhat silent on age of consent, there are many ethical issues to be overcome. Given that the eating disorder is occurring at a developmentally sensitive time, there are ethical considerations related to the ability and competence of an individual to accept or refuse help and to know what may be in their own best interest.
There are a number of concerns related to temporary or permanent impaired cognitions and memory loss with prolonged starvation. Often there are concomitant difficulties occurring that require different health care professionals to be working with an individual at the same time. Understanding these underlying issues will help the facilitator establish realistic expectations and provide improved ethical practice in working with these individuals. This information is important in creating boundaries related to areas of responsibility and the facilitator’s own limitations related to this population and running this group program.
A Model for the Highest Ethic of Care
In Britain the term Gillick competent and the North American idea behind empowered consent is competency based on a child or adolescent’s understanding and appreciation of what treatment is necessary and why, and the implications of receiving, or not receiving treatment (Manley, Smye & Srikameswaran, 2001). This concept also includes the right to refuse treatment (Doig & Burgess, 2000). However, this becomes complicated in the
49
case of individuals suffering from an eating disorder because refusal in the context of anorexia nervosa, for instance, is often part of the disorder itself (Manley et al.). As
Kenny (1997) suggested “… intellectual understanding is insufficient for competent decision making …” (p. 14) because adolescents have difficulty thinking of their own mortality or personal risk due to limited life experience and level of development.
The model considered here is based on a circle of caring and support that incorporates professional practice that combines rational and emotive elements as well as an intuitive component (Schulz, 2000; Sinclair & Pettifor, 2001). The model also extends personal and individual ethics to the social and cultural environment based on the idea that the social contract influences the quality of life of all citizens (Pettifor, 2001). The ethical principles are based on the overarching premise that respect for the individual remains paramount. However, feminist traditions in practice based on compassion and connectedness in relationships through loyalty and care for family, friends and community are emphasized in this group program (Pettifor, 2001, 2002).
Ethical practice is also based on viewing the eating disorder from a narrative perspective as external to the individual which has been shown to be helpful (Manley,
Smye & Srikameswaran, 2001). The individual is not seen as “the problem” – the problem is the problem - so the eating disorder is viewed as a separate entity (White &
Epston, 1990). This externalizing view helps to prevent perpetuation of a pathologizing attitude where the eating disorder is collapsed into the individual’s sense of identity, prevents self-blame, encourages agency and promotes a sense of hopefulness (Tomm,
1989). For instance, an individual would never be referred to as “the anorexic” or “the bulimic” so the way language is used is extremely important.
50
It is also important to nurture the working alliance (as described more fully earlier in
Chapter II) which develops faith and trust between client and therapist and also fosters a spiritual milieu in which the group can function. This means developing a warm and trusting environment where questions are answered honestly and directly within an interactive and collaborative process using simple, concrete information that is geared towards an individual’s level of understanding (Pope & Vasquey, 1998). Privacy and confidentiality takes precedence (Cormier & Nurius, 2003).
The ethic of care used in this group program includes the right of individuals to maintain their individuality and dignity through personal choice in discussing (or not), in whatever way they wish, the extent of the disease and its implications. The rights of the individuals involved should also be adhered to in the planning and choice of physical, emotional and spiritual support. Empowerment of the client to achieve their own agency is paramount but the counsellor needs to remain cognizant of the “…power of the anorexia, which may mask the authentic wishes of the client to seek wellness.” (Manley,
Smye & Srikameswaran, 2001, p. 157).
Clients should also be informed that confidentiality extends to the images they produce and that they have editorial privilege which means these images will not be shared with others without their written agreement. As Manley, Smye and
Srikameswaran (2001) stated “…the importance of honesty or fidelity cannot be overestimated because these individuals are extremely sensitive to the least sign of insincerity and circumlocution and they are highly suspicious of hidden motives (p. 160).
The intake process should note perceptions of the main issues, any significant life events and losses, plus cultural and contextual factors. The information should be
51
carefully evaluated to determine a focus, direction and appropriate intervention strategies given that the intent is developmental towards optimal functioning as well as to solve an immediate problem. A clear understanding of the context is necessary to identify and highlight the individual’s strengths, weaknesses, resources, skills, successes, personality traits and interests (Cormier & Nurius, 2003).
Discussion should also address the affects of increased starvation if a situation deteriorates, the complex issue of addressing competency, the legal issues of acting (or not), and the guidelines to be followed in the event of compulsory treatment. If there is increased medical instability due to refusal of interventions where an individual’s health and safety are severely compromised the client, family and staff need to have an ethical decision-making framework for breaking an impasse in ethical dilemmas (Pettifor, 2001).
Given that there is a lack of definitive guidelines in this area (Rathner, 1998) and it is compounded by the pressures of acting (or not) at a critical developmental time these types of interventions need to be handled thoughtfully and sensitively. As stated by
Manley, Smye and Srikameswaran (2001) “…intervening early on and aggressively may be necessary to prevent permanent stunting of growth and the development of osteopenia, as well as the indeterminate longer term effects of the eating disorder on fertility.” (p.
147).
Developmental consideration is at the heart of working ethically with this population because the clinician needs to determine the level of concrete operations the adolescent is in. For example, developmental age is only one aspect which has to be considered alongside pubertal, social and cognitive development (Manley, Smye & Srikameswaran,
2001). As Kenny (1997) suggested, caregivers should understand and be able to assess
52
the maturation of decision-making capacity in young adolescents. Also important, is to remember that ethical issues may need to be revisited a number of times because interventions are being considered in a developmental matrix that is rarely static.
Manley, Smye and Srikameswaran (2001) stressed that an eating disorder can dominate existence, or a patient can vacillate between more mature and earlier stages of development. The adolescent may be in a state of denial, have a range of unfounded and irrational feelings about therapy, or display a passive aggressive or ambivalent stance to interventions. At the same time there may be enormous pressures coming from the family to intervene immediately. Working together as a team involving family members in an advanced ethical decision-making process may be critically important for success because the individual and the family can have input before a crisis (Manley, Smye &
Srikameswaran).
It is also important to treat the adolescent as capable of making decisions and not assume a lack of competency either because of the eating disorder itself, or their inability to express their concerns and wishes. A great deal of research suggests that adolescents often have the experience of having their opinions and views dismissed by adults, and feminist research suggests that young girls particularly suffer from a loss of voice at this age (Gilligan, 1991; Gilligan, Rogers & Tolman, 1991; Mead, 1971; Pipher, 1994). It is the health care professional’s responsibility to ensure that discussion takes place in a context of responsible and compassionate caring, and in an atmosphere where the eating disorder is unable to dictate the outcome (Manley, Smye & Srikameswaran, 2001). It is also important not to make promises that cannot be kept.
53
The ethic of care should also encompasses timely recognition and effective treatment of psychiatric syndromes such as depression, anxiety, confusion, suicidal ideation and a wish for death that may be beyond the group process or the expertise of the professionals involved. Counsellors need to be acutely aware of their own limitations in this regard. The exceptional skills of the counsellor are critical in developing working alliances with a number of individuals and a variety of other team members who may be approaching the ethic of care from several different therapeutic perspectives. Successful implementation of this ethical model will be based on how successful the counsellor is in maintaining client confidentiality while at the same time providing a level of information that is acceptable to parents and other team member’s whose personal perspectives and theoretical expectations may be different (Cormier & Nurius, 2003).
Throughout the process the counsellor coordinates, arranges, mediates, monitors, consults and provides counseling. Using active listening the counsellor not only implements a loosely structured plan, but responds to difficulties and disruptions as they unfold by revising the plan, creating a new goal setting intervention or recycling through the process (Cormier & Nurius, 2003; Schultz, 2000). Extraordinary abilities in establishing empathy, warmth, genuineness and compassion is needed to flexibly and creatively tailor the framework of this program to best fit the needs of each individual.
The primary responsibility is to work in the best interests of the client (Cormier &
Nurius; Schultz).
The counsellor is not there to make feelings disappear, nor to decide for individuals what they should do, or to take steps for them. The primary role is to listen and help that person discover what they are feeling and help them identify their options for moving
54
forward. Sometimes it is simply a matter of giving permission to talk about a subject that is often taboo within the family or culture. The person is central, the family is important and cohesion needs to be built between the individual and their families at this time
(Pettifor, 2001, 2002; Schultz, 2000; Sinclair & Pettifor, 2001).
Tools and techniques to navigate the unknown and find meaning in their illness with a primary goal being to relieve suffering should be intrinsic to this ethical model
(Pettifor, 2002). One can counsel more ethically and caringly by providing a broader range of assessment and interventions options that not only include behavioural, emotional and cognitive sources for psychological issues but also include indigenous forms of healing practices as well (Berry, 1997, 2001; Blue & Darou, 2002; Pedersen,
1995).
To be with someone facing life threatening issues is a hard thing to do, but being there is the ultimate act of human kindness. This program is not so much a place, or a process as it is a philosophy for life that offers a holistic approach to health based on a spiritual approach to life. This approach should promise to accompany individuals not always with words, but through the shared creative process, a glance, or in silence. The goal should be to bring comfort and enhance the quality of life through skilled and compassionate physical, emotional and spiritual care that helps individuals work through traumatic, life altering challenges in the most affective way possible.
This Chapter highlights the need for the ethic of care to be offered in a way that views the client as the unit of care, recognizes the important status of the family and the psychological and physical impact that living with an eating disorder may have on an adolescent. These issues are important for the facilitator to understand how this group
55
program could impact individuals because this process explores central core issues around beliefs and values which link directly to the spiritual area of individuals’ lives.
The ethical approach should focus on living and strive to be a part of a multidisciplinary team committed to respecting autonomy, minimizing depersonalization and relaxing institutional regulations while providing excellence of care that more fully supports clients and their families. The therapist needs to be committed to bringing the individual and their loved ones hope, not only for today but for tomorrow and to be responsive to the cry of the spirit.
As an extension of the philosophical approach to the ethic of care, the following chapter discusses the more practical aspects of using a motivational enhancement therapy approach, a motivational interviewing style, a stages of change model, as well as a number of narrative techniques which are helpful in this group program approach. The ethical model should embody the basic philosophy to cure sometimes, to relieve often, to comfort always.
56
CHAPTER III
Theoretical Foundation
A Motivational Approach for Change
The principles and concepts associated with motivational enhancement therapy are discussed in this section, followed by a discussion on the stages of change model as envisioned by Prochaska, DiClimente and Norcross (1992). It also considers the advantages of using a motivational interviewing approach which is appropriate for working with eating disordered individuals in a group setting to explore ambivalence.
A narrative approach is also discussed because the individual is never seen as the problem, “the problem is the problem” which also affects the communicating style of the facilitator and the way language is used. These approaches have been found to be helpful in working with individuals suffering from various eating disorders because of the egosyntonic nature of the condition and the entrenched, distorted cognitions. The stages of change, particularly, is important and relevant for both the facilitator and the individual to understand as a concept and as a psychoeducational resource.
Motivational Enhancement Therapy
Motivational enhancement therapy principles are based on the premises that change is a willful choice, that the therapeutic alliance should be well established before confrontative interpretations are made, and that ambivalence is expected and welcomed as an opportunity to explore the costs and benefits facing the individual (Miller &
Rollnick, 1991; Miller, Zweben, DiClemente, & Rychtarik, 1992; Rollnick, Heather &
Bell, 1992; Rollnick & Miller, 1995). The concept is seen as a cognitive model with an interpersonal style that is shaped by a guiding philosophy and understanding of what
57
triggers change. This motivational approach is not restricted to formal counseling settings and can be successfully used in brief, single sessions or in group settings (Rollnick &
Miller).
This model can be used to depict stages of change for both the client and the helper
(see Figures 1 and 2), without formal assessments of any kind. Some evidence has suggested that indirect feedback in the form of mail intervention using this model can itself trigger behavioural change (Rollnick & Miller, 1995). The definition of this approach is best described as “a directive, client-centred style for eliciting behaviour change by helping clients to explore and resolve ambivalence.” (p. 325).
It is based on the idea that change comes from within the individual, that it is the client’s task to articulate and resolve ambivalence, and that direct persuasion is not effective for resolving ambivalence (Rollnick & Miller, 1995). The spirit of this counseling style is that it is generally a quiet and eliciting one based on a Socratic style of empathy and validation, empowering the client, being patient, honest and curious, and asking questions that further discussion. The counsellor is directive in helping the client resolve ambivalence. Readiness to change is not seen as a client trait but “… a fluctuating product of interpersonal interaction…” (Rollnick & Miller, 1995, p. 326).
Stages of Change Model
Motivational enhancement therapy principles are based on the Stages of Change model that was originally developed to deal with addictions by Proschaska, DiClemente and Norcross (1992). The transtheoretical model of change suggested that there are five stages of change in moving towards a particular outcome rooted in the premise that
58
treatment intervention is most likely to be useful when it matches the client’s stage of change (as shown in Figures 1and 2.
Precontemplation (unaware of a need for change or does not intend to change);
Contemplation (aware of a need for change but has not decided to make it yet);
Preparation (decided to take action in the near future and may have taken some action in the recent past that was not successful); Action (begun to engage in successful actions steps toward desired outcomes but has not yet attained the outcome); Maintenance
(reached the goal and now works to prevent sliding backwards and also works to consolidate gains). Relapse can occur at any time, but when clients reach the maintenance stage it is particularly important in preventing setbacks to equip them with strategies to manage that eventuality (Prochaska, DiClemente & Norcross, 1992).
Stages of Change - Client Maintenance stage “I am aware of what Action stage I need to do to “I am doing what is prevent relapse” needed to change”
Relapse stage Preparation stage “I need to review “I am looking at what I need for what I need to do change to occur” in order to change”
Pre-contemplation stage Contemplation stage “I may have something “I may have that I would like to something that I would change” like to change”
Figure #1 – Client’s Perspective – (Based on Prochaska, DiClemente & Norcross, 1992)
59
Stages of Change - Helper
Action stage Maintenance stage Active listening Active listening Supporting change activities Providing recognition & support Encouraging rewards for action Being prepared for relapse Supporting countering activities Monitoring & revising activities for change and countering
Preparation stage Active listening Relapse stage Elaboration of plans and goals Active listening Developing decisional balance Reviewing progress Identifying supports, skills, strengths Maintaining positive attitude but do not expect action Support learning from the past
Contemplation stage Pre-contemplation stage Active listening Active listening Giving feedback/information Looking for common ground Encouraging exploration of issues Providing feedback and information Weighing pros and cons but do not but do not expect action expect action Figure #2 – Helper’s Perspective (Based on Prochaska, DiClemente & Norcross, 1992)
Research has shown that this model is effective in fostering self-management change,
treatment interventions, treatment outcome effectiveness and persistence in therapy
(Prochaska, 2000). For issues around weight loss and addictions the use of stages shows
more positive treatment outcomes (Prochaska, 1999). The research has also suggested
that the client’s readiness to change is a critical factor in selecting intervention strategies
because if the client’s stage is mismatched, they will feel too pressured or possibly drop
out of therapy (Prochaska, 1999, 2000)
Prochaska (2000) sees the therapist in the early stages (precontemplation and
contemplation) as providing the function of being a nurturing parent, where they can
help the adolescent identify, try on, and experiment with alternative or different
60
possibilities. At the later stages (action and maintenance) where the individual is more motivated, the helper is seen more as a consultant or experienced coach.
Practitioners who are familiar with this change model will be more effective if they can identify the stage the individual is in because they can meet them where they are at, adjust their mode of helping to match, or offer the client emotional support or practical help in moving to a more productive stage. In this model, change is rarely linear and is considered more of a circular process where individuals vacillate back and forth between stages (Prochaska, DiClemente & Norcross, 1992).
Motivational Interviewing Model
Motivational Interviewing (MI) (Miller, 1983; Miller & Rollnick, 1991) offers a way out of power and control issues by exploring the costs and benefits of change, viewing the client as being capable of making informed decisions related to change, and viewing ambivalence as an understandable, justifiable, normal and appropriate state for anyone considering change (Killick & Allen, 1997; Gusella et al., 2002). This model is viewed as an empowerment model because even in the direst of circumstances, the individual’s right to self-determination and self-monitoring should be upheld (Duker & Slade, 1988).
A basic interaction technique in this motivational interviewing approach is captured by the acronym OARS: (1) Open-ended questions, (2) Affirmations, (3)
Reflective listening, and (4) Summaries. Although closed questions are useful, open- ended questions allow forward momentum that keeps the lines of communication open.
Affirmations recognize clients’ strengths, explore prior attempts at change, and help build rapport. Reflective listening is a more directive approach that concentrates on listening intently, guiding the client to certain materials and focusing on their change talk.
61
Summaries encapsulate the relevant highlights in the conversation and describe the essence of several client statements with regard to meaning, beliefs, values or effect
(Miller, & Rollnick, 1991; Rollnick, Heather & Bell, 1992; Rollnick & Miller, 1995).
Motivational interviewing (MI) can help the therapist assess a client’s current relationship with the eating disorder and also help the client to consider what may be maintaining the status quo and to contemplate freely and creatively alternative ways for moving forward. MI seems to be effective with involuntary clients who are not yet invested in identifying any outcome goals (precontemplation/contemplation stages) often because they are highly motivated to maintain the status quo, they do not believe they have a problem, or they think the problem lies elsewhere (Gusella et al., 2002).
Contemplation acknowledges the problem but the individual provides justification to why they are not ready to change or why they are unwilling to devote time and energy to solving it. This approach is crucially based on the assumption that neutral consideration of options is more likely to lead to change than either persuasion or prescription (Killick
& Allen, 1997).
The counsellor’s role is to support the client in understanding that there is no right way to change but that change is only limited by their own creativity to finding the way that works best for them. Miller et al., (1992) suggested that many clients are often failed self-changers who may have tried to alter their behaviours previously, and that they are already demoralized and discouraged when they come to therapy. Individuals may already believe that the issue is beyond their control so it is really important that counsellor highlight individual’s skills, strengths and past successes. Particularly in areas
62
where they observe only failures because they may already believe that the issue is beyond their own control by the time they ask for help (Miller et al.).
Rollnick and Miller (1995) suggested that one strategy is to review good things and less good things to avoid labeling a behaviour as a problem when the client does not see it that way. Motivational interviewing is a technique for exploring, for instance, the pros and cons of having an eating disorder as the good things and not so good things about changing. Rollnick and Miller suggested that if it becomes a manipulative technique, or is seen as a technique that is used on people, then the essence of this approach has been lost.
Motivational techniques are also a way of not allowing the eating disorder to become the elephant in the room where everyone knows it is there but refuses to talk about it because of lack of acceptance, shame or embarrassment. Negative stereotypes have sometimes been reinforced by professional paradigms and popular ideologies. Popular misperception is that those most vulnerable to developing an eating disorder are females who are young, white, middle- to upper-class and perfectionistic high achievers
(Lelwica), 1999). Using a motivational model also helps to reduce the hyper-attention on stereotypes based on race, class, age, sex, and economic privilege and the shallow perception that individuals are only interested in looking good. It reduces the disorder to more normalizing proportions by taking the emphasis off pathological extremes.
Empathy is also a critical factor in this approach because it involves being able to put yourself in the client’s shoes. In effect, seeing the world through the client’s eyes so that you can think about things the way the client thinks, feels and experiences them. If the client feels that they are understood and accepted they are more able to open up to their own experiences and share those experiences with others (Miller & Rollnick, 1991).
63
Using this technique an opportunity exists for individuals to perceive a discrepancy between “where they are and where they would like to be …” (Miller et al., 1992, p. 8).
Clients may be more motivated to make important life changes if individuals perceive that their current behaviour is preventing them from achieving future goals (Miller et al.).
There is also the opportunity of reframing issues around tolerance which may suggest that the individual does not have a built-in warning system to indicate when he/she has had enough. Motivational interviewing may open the door for the client to consider that where they may have thought there was no problem before, may actually be the problem.
Insight may be a case of recognizing the risk of overdoing things before it is too late
(Miller & Rollnick, 1991; Miller et al., 1992; Rollnick, Heather & Bell, 1992; Rollnick &
Miller, 1995).
Summaries can be an effective way to highlight salient points, to shift attention or direction and build rapport by showing interest in the matter at hand. There is also a paradoxical element to this technique that the counsellor uses to roll with resistance instead of opposing statements made which is useful with clients who are entrenched in their thinking or highly oppositional. Rollnick and Miller (1995) suggested that resistance is decreased rather than increased because the client’s faulty logic is not being reinforced by having to defend their position. There is also no client-counsellor hierarchy being imposed because counsellors do not force new ways of thinking on the client.
Staying motivated to change hinges on believing that change is possible and critical to maintaining hope that things will ultimately get better. The key to success for the client is developing a belief in their own self-efficacy by being responsible and taking actions towards their own betterment. The goal is not based on insight related to deep
64
psychological processes but to re-establishing a connection to an individual’s ground of being and their sense of themselves before the start of the present difficulties. The objective is also to gain perspective around the issue and to provide the opportunity to view how things have changed over time (Rollnick & Miller, 1995). The goal is to tune into the past while creating forward momentum to create change for the future.
A Narrative Approach
Linda Nead (1990) suggested that narrative is the transformation of representation into reality, the demonstration of its truth and the discovery of its meaning. She also suggested that narrative is fundamental to the effectiveness of myth and the unveiling of reality because it reinforces for us a conviction that the world is real, consistent, and coherent. A major obstacle for eating disordered clients involves equating their identity and dignity as a person with the dominant problem in a negatively saturated story.
Therefore, it is important to separate their identity by externalizing conversations and inviting them to discuss or enact both how they have been influenced by, and able to overcome, the problem (White & Epston, 1990).
Below are some salient narrative techniques that are used with the motivational interviewing style to further the conversation between group members and to find out how individuals might react in specific situations. These narrative techniques also form the basis of exploring the individual’s cognitive thinking and the way they use language in perpetuating negative patterns about themselves and their world. The techniques could also be used as the basis for a psychoeducational component either when disseminating information on different types of therapies used in treatment, or as a technique to be used as a direct lead into an art activity. For instance part of the psychoeducational resource
65
package recommends providing the group with an overview of different types of therapies that they may come across in treatment and it is recommended that narrative therapy be included. The following techniques are recommended for use within this group program as conversation, for dialogue within the art process, or as a conversation with the other through the art piece:
Imagining:
• An angry friend is ticked off with you for not doing what you were supposed to do.
What does this mean for you? Articulate or draw it.
Externalizing:
• How can you change the outcome? Create a new story? Empower yourself or others?
How do you create a new perspective? How can I help? How can the art help? Identify resources, actions, thoughts that can help. Draw a picture.
Revisioning:
• Consider unique outcomes and develop into a new story, new lifestyle scenario.
Create renewed agency by writing or drawing..
Deconstructing/Reconstructing:
• Name the problem, draw the problem;
• Define the problem in the individual’s own language or images;
• Separate the problem from the person;
• Look at the impact of the problem and the affect on life and relationships;
• Make a distinction between each issue and itemize in point form;
• Identify resourcefulness, not giving into the problem, what has worked before;
• Describe future consequences, long term effects, isolationist lifestyle etc;
66
• Visualize what life would be like if problem continues to maintain power over life;
• Visualize what life would be like using “What if….” statements ;
• Draw new distinctions, focus on strengths, skills and resources;
• Explore the relevance of influencing factors;
• Consider the possibility that the problem might just take it’s course;
• Explore barriers to taking an alternative course, what that new life might be like;
• Expand understanding of the restraints that block defeating the problem;
• Decide on the position the individual wants to take in relationship to the restraints.
Reconstruction/Resourceful Phase:
• Times when the individual was successful before in defeating the problem;
• Imagine or draw those times when you stood up to the problem;
• What is the next step? Is the individual ready to commit to a new life course?
• Invite the individual to construct alternative self-definition, new self description;
• Identify new self structure with building blocks for getting to new outcomes. (It provides energy, hope and motivation for change to propel onto a new life course.)
• Recruit a new audience for the new life course so that the new story has a chance for survival and can endure, and that allows the old story to fade away;
Setbacks:
• Discuss the possibility that setbacks happen. Analogy of actors forgetting their lines;
• Individual will face setbacks (called hangovers);
• Anticipate how to handle slips back to old patterns of behaviour;
• The need to arm the individual to defeat the hangover, and prevent discouragement setting in.
67
How to proceed:
• Identify preferences and ways to proceed;
• How can the therapist best help with that?
• What will those choices look like in the future?
• Use “I wonder …” statements to consider whether identifying differences empowers the individual to prefer one choice over other choices;
• Look at preferences – what do they look like, possible consequences for future life and relationships.
Although the stages of change model is used extensively in therapeutic work, often the value of the model is overlooked from the perspective of the helper. Hopefully, this discussion was helpful in understanding how both the helper and the helpee can use the stages of change to more accurately meet the individual where they are at. Understanding how motivational enhancement and motivational interviewing work highlighted the importance of language in that exchange. Particularly important is paying attention to how the individual uses symbolic and dialogic language to tell their own story. The following chapter expands on the narrative approach by exploring the concepts behind self that motivate beliefs and values related to developing a sense of personal identity.
68
CHAPTER IV
Literature Review - Self
The concept of self has been prominent across psychological theory perhaps because it has been one of the central ideas underlying Western thought and notions of the good life, justice and freedom. This concept also seems inextricably linked with delineating fundamental human motives and the highest forms of existence (Rachels, 1993). This chapter discusses the evolution of the concept of self and the adolescent sense of self. It explores how an individual might interpret their own sense of self and also how a helper may interpret an individual’s sense of self who comes to them for support.
Understanding the developmental matrix of the adolescent sense of self is particularly relevant because much has been written on this topic related to eating disorders. Health care professionals need to understand the impact of earlier models of self because they can determine their actions. These models become particularly relevant and important considerations when discussing adolescents’ sense of self, and their beliefs and values, because individuation and separation is often based on these powerful earlier models.
How an individual understands their own sense of self and how this relates to the way they function spiritually is critical to running this group program. Both therapist and client may examine them carefully, embrace these earlier models to a point, but not consider them as the only models available as a prescription for what should happen.
The Notion of Self
Who we are (or who we think we are) can have a gender component based on the way we understand our own sexuality and be defined by the cultural group with whom we align ourselves (Stevens, 1998).
69
In 1890, an early theorist William James suggested that our sense of self has three components that permeate everything we do and how we do it as social beings. Our spiritual selves (emotions, ideals, values and inner sensibilities/sensitivities), our material selves (physical bodies and possessions), and our social selves (relatives, friends and reputation). Self evolves through going out into the world and interacting with others
(Burkhardt, 1984).
In the 1930’s to 1950’s the theory of Symbolic Interactionism was coined by such theorists as C. H. Cooley (1922), A. R. Mead (1930) and H. S. Sullivan (1953) who understood our sense of self to be sociological in nature and developed with others in society through symbolic interaction. Mead suggested that we define ourselves through interaction with others and through internalizing society’s view of ourselves. Cooley saw self as being developed through a looking glass self – a reflective appraisal of ourselves through a kind of mirror effect.
Winnicott (1953, 1971a) and Bowlby (1973, 1979, 1988) in England, and Jacobson
(1954) and Mahler, Pine and Bergman., (1975) in the United States felt a child’s early attachment to the mother figure and the emergence of the self as an independent entity were significant. Winnicott was interested in the idea of a transitional object whereas
Mahler emphasized the emergence of the sense of self through separation and individuation (Corsini & Wedding, 2000).
Festinger (1954) coined the term Theory of Social Comparison that suggested we evaluate ourselves through comparison with others particularly in the absence of objective standards of correctness. Our richest sources of evaluation are those around our own age and capabilities whom we usually compare ourselves to at a slightly higher level
70
and it has a uni-directional component for continuous upward mobility. He agreed with the idea that a sense of self is a product of social interaction within our society.
In the late 1970’s there was a cognitive revolution and the Cognitive Self became the dominant view in Western psychological theory. This view focused on the Self as a kind of internal, information processor that replaced the idea of self based on ideas and emotions. Our self-concept was based on our self-schema - an organized collection of beliefs and feelings about ourselves that defined our self-identity. A study by Klein,
Loftus and Burton (1989) suggested that we are constantly self-referencing and that more elaborate and categorical information relevant to the self is dealt with more efficiently, recalled more and noticed more. In the absence of others we often have a dialogue with ourselves – a kind of pillow talk with the ego.
There are many different theories recognizing the role of identification and the transformation of the personality over the life cycle (Erikson, 1968), the importance of interpersonal relationships (Sullivan, 1953) and the social, political and cultural factors in the development of the individual (Horney 1940; Fromm, 1955). There is also reason to question whether many of these earlier models accurately reflect men’s lives or women’s experience in terms of the idea of being in relationship as a sense of self that reflects what is happening between people (Gilligan, 1981, 1992). Many early models focused on increased separation or self-development hierarchies as opposed to development of greater capacity for emotional connection to others, contributing to an interchange between people, or playing a part in the growth of others as well as one’s self which is a central premise underlying this project (Miller, 1981).
71
Facilitators, and the individuals who come to them for help, need to embrace the idea that connectedness and relationship does not detract from or threaten a sense of self but may very well enhance it (Pipher, 1994). If being in relationship with, or picking up on the emotions of others, or attending to the interactions between individuals becomes a natural way of acting and being in the world then it becomes something that is seen as being valuable, satisfying, motivating and empowering (Miller, 1981). These concepts become important in fostering the self-esteem or self-worth of adolescent girls who often feel that they must sacrifice relationship or connectedness in favour of autonomy and increased separation in their desire for acceptance (Pipher, 1994). Adolescents (both boys and girls) should not have to feel that independence is only achieved in separation. It is important to cultivate that notion in them.
Miller (1981) suggested that maintaining relationships with significant people in life is still the most important goal yet, male and female adolescents in Westernized societies receive the subtle message that to be interdependent equates to some kind of weakness or inferiority status (Gilligan, 1981, 1991). Striving for relationship with others should not be viewed as something alien or threatening that needs to be hidden or held in check.
Interdependence should be thought of as something that is desirable, sought after and strived for in the search for greater self-actualization, self-awareness and communion.
Interest is also growing in the psychologies and therapies of other cultures and the recognition that Western psychotherapies may have significantly underestimated the power and potential of Asian psychotherapies. The most influential ones being Buddhist,
Hindu, Tao and neo-Confucian systems that originated in different parts of Asia (Walsh
2000). These Asian psychotherapies are known as the perennial religions or wisdom
72
traditions because they are ancient, and their religious, philosophical and psychological divisions have significant commonalities and similarities related to transcendent ideas
(Walsh). Greater understanding of developmental psychology has also fueled interest in the transpersonal aspects of the individual’s ability to move beyond conventional stages of development (or arrested development), to greater levels of knowledge and understanding (James, 1958; Walsh).
The Adolescent Girls’ Sense of Self
Pipher (1994) in her attempt to understand adolescent girls and the epidemic of eating disorders makes a strong argument that a loss of self may be a significant contributing factor in eating disorders. She argued persuasively that even although young women today should feel freer, the demands being placed on them make them more oppressed with the result that they tend to be less whole and androgynous than they were at age ten. In Reviving Ophelia (1994) she stated:
…they are more appearance conscious and sex conscious. They are quieter, more
fearful of holding strong opinions, more careful what they say and less honest. They
are more likely to second-guess themselves and to be self-critical. They are bigger
worriers and more effective people pleasers. They are less likely to play sports, love
math and science and plan on being president. They hide their intelligence. Many
must fight for years to regain all the territory they have lost. (p. 318).
Pipher (1994) also argued that the pressures in Westernized cultures are girl poisoning because of their emphasis on superficial beauty, sophistication and thinness.
She suggested that many girls who are balanced, and well adjusted before puberty are transformed into sad and angry failures with a truncated sense of wholeness by the time
73
they hit junior high. Even the most hardy of girls can become overwhelmed and symptomatic because they are not immune to the pain and pathology that is incited by a junk culture at this stage in their development (Pipher).
Frieden (1964) in the Sixties, described it as the problem with no name where adolescents have a sense that something is seriously out of kilter but they cannot articulate the source of their misery. The analogy she used is that prepubescent girls are curious, resilient and optimistic but by the time they reach adolescence their selves have crashed and burned in a social and developmental kind of Bermuda triangle. These adolescents become less assertive, less energetic and more self-critical and depressed
(particularly about their own bodies).
In psychology, diverse writers such as Mead (1971) and Gilligan (1982, 1991) have documented the phenomena also but have often had difficulty explaining it. Why do the selves of adolescent girls become fragmented and splinter into mysterious shards of contradictions? Pipher (1994) found many of the adolescents she worked with elusive and slow to trust adults and she contemplated why this might be. She stated that adolescents are “… easily offended by a glance, a clearing of the throat, a silence, a lack of sufficient enthusiasm or a sentence that does not quite meet their needs…… their voices have gone underground and their speech more tentative and less articulate ……Much of their behaviour unreadable.” (p. 5).
Many writers document this time as being marked by greater mood swings, fluctuations between energy and lethargy, vacillation between confidence and self doubt
(de Beauvoir, 1952; Frieden, 1964; Gilligan, 1982, 1991; Mead, 1971). Wholeness is shattered by the chaos of adolescence where many girls become expert female
74
impersonators and their self-worth hinges on external, societal dictates (Pipher, 1994).
Their problems manifest in complicated and metaphorical ways such as eating disorders and self harm (Frieden; Gilligan; Mead).
Simone de Beauvoir (1952) suggested that adolescence is when girls realize that it is a patriarchal society where men have the power and their only access to it is to become submissive and adored objects. Pipher 1994) suggested that girls do not suffer from penis envy as Freud might have suggested, but suffer instead from power envy (Arlow, 2000).
These adolescents stop being and start acting out who they think they should be. Instead of asking Who am I? or What do I want? They start to think about what they have to do to be liked and to please others (Pipher, 1994). Mead (1971) stated that many cultures perpetuate a system where female voices go unused or under-appreciated.
A sense of power is critical to one’s mental health, and as Pinderhughes (1989) stated
“…… everyone needs it” (p. 110). He also indicated that counsellors need to understand their own experiences, feelings and behaviours related to having or lacking power before they can effectively help their clients. As part of a self-reflective process, counsellors have to acknowledge their own need for power, understand how they react when they exercise power or experience the lack of it, and know how to avoid abusing it (especially as it pertains to the clinical relationship) (Ramsey, 1997).
Ramsey (1997) suggested that women tend to define power as having the strength to care for, and give to others. Women also relate having power over natural forces to include control over their own bodies. Practitioners need to define power in the client’s context, have a wide repertoire of counseling skills that emphasize power acquisition and management, and be able to develop and maintain counsellor/client coalitions to employ
75
these skills (Ramsey). Power and control may be central issues for individuals with eating disorders, counsellors should know how to empower, increase personal power, or reduce the power of the presenting problem over the individual (Pedersen, 1995).
Pipher (1994) suggested that adolescent girls experience a conflict between their autonomous selves and their need to be feminine, “…between their status as human beings and their vocation as females.” (p.7). According to Pipher, adolescent girls sense a pressure to be something they are not which is manifested in their authentic selves going underground. For the eating disordered person life becomes a charade full of suspicion, and feelings of shame and guilt begin to separate them from friends and family.
Kilbourne (1999) suggested that female children and adolescents are being bombarded with media messages that emphasize sexuality and thinness to such an extent that they often come to believe that they are being judged on the basis of their outward appearance alone. The indoctrination of young people is compounded by the fact that cognitive and linguistic abilities are developing in tandem with physical and psychological growth which makes it doubly difficult for many adolescents to articulate their concerns. These developmental changes happening to their minds, bodies and hormones are exacerbated by certain expectations of the society.
Mead (1971) suggested that adolescence is occurring in a culture that encourages the idea of autonomy and separation from family at a time when they may need family support the most. Independence is occurring at a time when they are self-absorbed with identity formation and trying to work out who they think they should be which may be a deadly combination. At this time, closeness and protection of family are forfeit in favour of their peers who are also struggling with the same concerns (Pipher, 1994).
76
Pipher (1994) suggested that many adolescent girls today are sadder, angrier and grieving for a simpler time when things were much less complicated. For some it is manifested in trying to control physical and sexual development. Lelwica (1999) suggested that many adolescents have forgotten or repressed painful experiences and transposed a nagging sense that something is not quite right with the world into hating themselves and their bodies. Abrahim and Llewellyn-Jones (1992) suggested that many eating disordered females confuse sex and love that is expressed in conflict around body image. Hardman and Berrett (2001) suggested that they struggle with relationships because they have difficulty loving themselves and find it difficult to accept that others will truly love or accept them for who they really are.
Erikson (1968) and Pipher (1994) would probably both agree that distancing from family in the individuation process is a healthy developmental shift, but coupled with physical and psychological changes it may come at a heavy price. Although adolescence for both boys and girls has always been hard, Pipher argued persuasively that cultural changes over the last couple of decades is making it harder and creating a milieu where something new is happening. Most adolescents recover from this temporary maelstrom, but many carry unexamined traumatic experiences that come back to haunt them in adulthood and some show up as adults in therapy wanting to lose weight, rescue their children, or save their marriages (Lelwica, 1999).
This chapter raised concerns around the way a sense of self develops due to the pressures in westernized cultures based on a patriarchal society, emphasis on superficial beauty and thinness fomented by media hype, and the need to fit into cultural and gender expectations. It also explored the way earlier models can bias the way health care
77
professionals across the board understand and treat the individuals who come to them for help. Westernized beliefs and values around development and maturation bias the way health care professionals understand and interpret developmental factors associated with the chaos of adolescence, and/or the potential loss of self or voice in adolescence.
Particularly relevant to running this program is the growing interest in incorporating
Eastern philosophies into Westernized notions of self and healthy living that emphasize the spiritual aspects of individuals’ lives and the impact of fostering a model of self that also emphasizes connectedness and relationship. These notions are explored more fully in the next chapter.
78
CHAPTER V
Literature Review – Spirituality
This chapter discusses several concepts and links between spirituality and health. It traces the historical connections between spirituality and healing over the ages to the present day, the understanding of spirituality related to Aboriginal, Asian and Western societies, as well as the spiritual connection to eating disorders. The discussion also explores the burgeoning interest in the search for a spiritual life and a new definition of what it means to be a spiritual person.
The information explores briefly the importance of the role of faith, the value of truth and the power of forgiveness related to the development of the spirit. The chapter concludes with a discussion of the limitations of a spiritual approach and identifies spiritual themes and topics that are important to individuals suffering from an eating disorder. The spiritual themes and topics identified in the research form the basis for developing the focus of the spiritual components for this group program.
The Spiritual Journey
Starratt (1996) suggested that, to never engage in discussion about values and spirituality is to communicate, by default, the message that these things are irrelevant to the public life of a community which in turn creates a moral vacuum. The inclusion of these topics should be more intentional and purposeful in everyone’s daily interactions because they are embedded in the circumstances of everyday life (Starratt). Meaning- making should be a communal endeavour to avoid blinkered vision and self-serving outcomes.
79
In a culture that surrounds and bombards us with messages and images that appeal to materialism, narcissism and consumerism, the challenge is often reorganizing lived experiences into coherent and cohesive patterns that act as guides for right and defensible actions (McIllmurray, Francis, Harman, Morris, Soothill & Thomas, 2003). Wholeness comes down to making choices that lead to greater self-esteem, aliveness, wholeness, health, love and justice rather than toward isolation, alienation, fear, prejudice or a gradual death of self (McIllmurray et al.). Viewed through the lens of spirituality, interactions become sacred space where people make a journey toward greater understanding of self (as scholar and actor), subject matter and truth.
This project is based on the premise that spirituality encourages and facilitates positive changes in a community and the lives of those living within it. Also, that people who fail to realize the potential of spiritual development miss the strength of its application. Having said that, spirit is not something easily acquired, learned by reading a book or attending a leadership workshop. It is even questionable whether spirituality can be learned at all (Otto, 1957). However, most of us recognize people with spirit because they emanate special qualities that combine head and heart, mind and body, intellect and feeling towards others and are slow to pass judgement.
What is Spirituality?
The heart of spirituality has to do with what a person believes, values, dreams about and is committed to. An individual’s interior world becomes the foundation of her or his reality and a person’s values, beliefs and spirituality form and guide behaviour
(McIllmurray, 2003). A set of values may be a more appropriate grounding for aspiring and practicing spirituality because it shifts the focus from characteristics of leadership, to
80
the character of leaders, and from a prescriptive form of leadership to leadership as an act of morality (Creighton, 1999). Leaders with genuine spirit have a deep sense of values and beliefs and a willingness to expose those beliefs and values for inspection and dialogue with others (Creighton).
Starratt (1996) suggested that a wholesome and healthy person possesses three main qualities: (1) autonomy, (2) connectedness, and (3) transcendence. Autonomy means being your own person and taking responsibility for your own actions. Connectedness is being aware of relationships with others, the relationship with culture, tradition and ritual, and the relationship with nature and the natural universe. Transcendence displays a desire to turn toward something greater than or beyond oneself. This notion is more of a
Western understanding and would become problematic from a Toaist perspective where the intent is to become like a God. However, the spiritual journey is a personal and communal search for truth in the form of deeper and stronger layers upon which to justify actions in the world and identifying core values and beliefs that support pedagogical choices.
Spiritual Assessment and Intervention
Psychosocial assessments rarely include substantive spiritual content and when questions are asked they are often limited to discovering a client’s religious denominational affiliation and identifying potential social support systems beyond family caregivers (Michalec, 2002). Questions about a person’s spiritual history, how the client’s spiritual life might be related to current problems, whether the client has unmet spiritual needs, or whether including a spiritual dimension into the care plan would be appreciated, tend to be avoided (McIllmurray et al, 2003).
81
Often the agency providing services may be governmental or non-sectarian and view the spiritual concerns of a client as an inappropriate area of inquiry. Too often, individuals are only offered spiritual resources when they are dealing with death or dying which misses the opportunity to incorporate spiritual inquiry and discussion as an integral part of life (McIllmurray et al, 2003). An article published in the February 2002 edition of the Canadian Medical Association Journal suggested that patients want care providers to respect their spiritual beliefs and feel better cared for when this important part of their life is recognized.
Although information about the spiritual background, wishes and needs of a person may be as important as information about physical health, psychological functioning and social support, health care professionals may feel (and be) ill-equipped to respond when a client articulates spiritual needs (McIllmurray, et al., 2003). Therapists may even miss subtle overtures in this direction because they are not trained to recognize this dimension in a client’s life (McIllmurray et al.). Developing spiritual resources may be involved in coping with a diagnosis that can provoke deep unsettling feelings of doubt and despair with the result that achieving spiritual closure or reconciliation may take on special importance at this time (Roff & Parker, 2003).
The Link Between Spirituality and Health
Richards et al., (1997) found that a spiritual focus was important for the healing process of many women recovering from bulimia nervosa who found solace in their faith and prayer. Hardman and Berrett (2001) found that religious and spiritual issues were sometimes intertwined with the pathology of eating disorders. These researchers found that religious issues can contribute to, and exacerbate many of the negative aspects of the
82
disorder. Religious coping has also been found to be instrumental in helping individuals to recover and heal, and it can be a significant source of support for family members and others who give care to people dealing with life threatening illnesses (Michalec, 2002).
Some clinical studies show that those who actively practice their faith are less likely to experience mental and physical illness, enjoy improved recovery when ill, and have enhanced ability to cope with illness (Erricker, 2002; Roff & Parker, 2003). McIllmurray et al., (2003) found those who actively practice their faith are less likely to experience mental and physical illness, enjoy improved recovery when ill, and have enhanced ability to cope with illness. Even with ailments considered to relate to biological dysfunctions there is less likelihood of adverse outcomes in those individuals who are involved in their faith (Hull, 2003).
Baxter (2001) found eating disordered patients used significantly more religious practices compared to other patients. Kristeller and Hallett (1999) found that meditation was helpful as a calming influence and creating a non-judgemental stance toward themselves. Hardman and Berrett (2001) found that bingeing behaviour decreased and a sense of control increased when religious practices were used. Many women also found that giving up conscious control over eating and putting it in the hands of a higher power led them to have greater control.
However, many others found a tremendous fear of losing control and contemplating surrendering or letting go as an act of faith was terrifying for them (Hardman & Berrett,
2001). In a survey conducted by Hall and Cohn (1992; as cited in Richardson et al., 1997) fifty-nine (59%) percent of the results from women suffering from bulimia claimed that spiritual pursuits had been helpful. Others said that a spiritually oriented 12-step program
83
had been beneficial. However, despite these positive findings, therapeutic interventions that explicitly take into account the spirituality and religious traditions of individuals and their families are rare (Erricker, 2002).
An Historical Connection to Spiritual Healing
Animistic cultures, both past and present, believe that spirits control everything including sickness and health. Even today many ancient religions and customs passed down in Eastern and African cultures consider the shaman or witch doctor to have access to the spirit world with the ability to invoke special spiritual powers. When a member of a tribe falls ill, it is often the shaman using spiritual interventions that brings the individual back to health with special herbal concoctions and brews (Elkins, 1999;
Walsh, 1999a, 1999b). The art and study of Indian and Chinese medicines are ancient practices that do not place great emphasis on Western medicines and methodologies.
They emphasize the energies of the body (Blue & Darou, 2002; Miller & Cook-Greuter,
2000; Walsh, 1990a, 1990b).
An Aboriginal Connection
In many aboriginal cultures (and ancient Eastern cultures), there is belief in the universe in balance, being interconnected, living in harmony with nature and the environment, and viewing humans as the mirror of the universe, where vital energy is channelled through the body. Health and wellness embraces the idea of balancing all things with transcendental forces at work. First Nations people view sickness as a disruption or imbalance in the flow of energy (similar to the qi or chi in Asian cultures) that manifests as a negative force in the body. Being in a state of balance or harmony is seen as the ultimate spiritual health, manifested and experienced in the idea of “the Holy”
84
(Blue & Darou, 2002; McCormick, 1996; Maher & Hunt, 1993; Miller & Cook-Greuter,
2000; Otto, 1957; Walsh, 2000).
An Asian Connection
The concept of spiritual healing has a different meaning in different cultures and there are many different healing practices that represent profound insights on well being.
Ayurvedic medicine, is a 6,000 year-old tradition that is still practiced by more than
350,000 physicians in India where the central premise of wellness is the degree that the body and spirit are in harmony. These practitioners prescribe meditation, massage, yoga, fasting and herb preparations combined with diet and sleep modification (Smolan, Moffitt
& Naythons, 1990; Walsh, 1990a, 1990b, 1999a, 1999b, 2000; Walsh & Vaughan,
1993). The ancient notion of the Yin and Yang (the idea behind the body and spirit being connected and balanced) is now endorsed by many people all over the world. This idea implies that everything we do to (and with) our bodies becomes manifest through the spirit (Hua, 1991, 2001; Smolan et al.).
A Western Connection
In Western societies today, spirituality and healthcare are rarely discussed together.
Physicians often tend to dismiss the idea of a Creator and disregard a spiritual dimension in the lives of their patients (Genius, 2003). Scientists often fail to acknowledge the validity of a spiritual dimension in the everyday lives of people by claiming that spiritual pursuits are childish or mere fantasies that conflict with scientific truth (Genius). Health is often defined in strictly medical terms by physicians with the role of the spirit being relegated to religious specialists who have little input on health and well being.
85
It is argued here that spirituality and science can go hand in hand and that dismissing the spiritual dimension diminishes the sense of purpose that individuals need to live healthy and happy lives (Gambone, 2003). A spiritual perspective can help individuals interpret the events of life, and the framework of spiritual belief may form the basis for how people make decisions in personal and health matters that ultimately motivate behaviour. A spiritual foundation can be a powerful means of coping in times of difficulty and illness, and living without a clear sense of meaning or purpose may rob individuals of their joy. Conversely, and regardless of theological differences, a dose of
“good spirit” in peoples lives may contribute toward making us better people and more able to cope with life’s transitions and tribulations (Gambone).
The Spiritual Connection to Eating Disorders
Down Through the Ages
There is speculation that disordered eating has been around since humans began walking the planet and developed ritualistic behaviours related to religious practices.
Individuals made food offerings to their various Gods or Spirits to appease or honour them. If you ask most adolescents girls how long they think eating disorders have been around they will usually estimate about fifty years and they are usually surprised to find out that anorexia nervosa was first described more than one hundred and fifty years ago
(Le Grange & Lock, 2004; Robin, Gilroy & Dennis, 1998).
Overeating has also been recorded for over two millennia and Roman banquets of excess are legend where vomitoriums were a natural part of the festivities so that individuals could gorge themselves, vomit and return to eating and drinking. Some
86
ancient Egyptians would consume laxatives (known as emetics) to make them vomit on a regular basis to prevent disease through contaminated food (Kuehnel, 1998).
Lelwica (1999) suggested that the human body has been a crucial subject related to
Euro-American history, religious beliefs and rituals (particularly Christian ones) that articulate experiences of longing and pain. She goes on to suggest that Christian attitudes and ideas are deeply ingrained in our culture’s moral fabric and that even in medieval times, Christian symbols and beliefs “… played a central role in mediating girls’ and women’s relationships to their bodies, to others, and to the uncertainties and vicissitudes of their daily lives.” (p. 5). In comparing deities from Eastern and Western religions it strikes me as interesting that Jesus is always visually portrayed as lean or verging on emaciation whereas Buddha and the like are portrayed as chubby. I wonder if this visual message has somehow been internalized into the Western psyche on some level.
As far back as the 13th century there were heretics and ascethetes who practiced their religion by fasting. Some females known as holy anorexics were canonized as saints.
Saint Catherine of Siena, who lived in the 14th century, starved for very long periods of time as a form of spiritual fulfillment and worship. She forced herself to vomit as punishment for breaking her sacred vows and was able to impact the religious and political landscape in her day because of her notorious behaviour (Lelwica, 1999).
Another common belief is that women have learned to despise their bodies based on the male hierarchical stories of the Bible that perpetuate the idea of women being created from Man, the ones responsible for sin in the world (and therefore, more inclined towards deceit), and subject to unhealthy desires of the body (Cox, 1997). Whereas men have tended to be associated with virile qualities such as judgement, courage and stamina,
87
women have traditionally been considered irrational and in need of protection, or alternatively seen as some kind of Madonna figure perpetuated by the Virgin Mary (Cox).
Some researchers suggested that scorn for the female in general, and women’s bodies in particular became a basic element of Christian practice and symbolism that has become embedded in society’s cultural views and norms (Gross, 1996). Goldberg (1997) suggested that mainstream religions such as Judaism and Christianity and the symbolism expressed through them have been chiefly concerned with perpetuating the idea of a divine God who is interested in furthering the notion of male authority that carries greater power.
The Spiritual Connection Today
Leichner and Manley (2003) suggested that perfection, purity and self-sacrifice are still important themes expressed by individuals dealing with an eating disorder today.
Many theorists and counsellors currently believe that individuals dealing with many addictions are suffering from a disconnection from their spiritual and creative selves and the hopelessness that comes from believing that their lives have no meaning or purpose
(Maher & Hunt, 1993; McNiff, 1981, 1988, 1991, 1998).
Whereas in the past the emphasis was on striving for perfection in this life linked to spiritual gains and salvation in the next, the modern eating disordered individual views perfection in terms of the society’s ideals of physical beauty (Denmark & Paludi, 1993;
Lelwica, 1999). Advertisers perpetuate this notion by suggesting that only if we look good and have the right product can we protect ourselves from the humiliation and shame of rejection, and the sense of failure that comes with not looking perfect and having the right homes, cars or stylish things (Kilbourne, 1999).
88
In Search of the Spiritual Life
Today, there is growing interest in the connection between spirituality, faith and healing. Some research suggested that for many Westerners there is interest in returning to traditional religious values and practices. The publishing industry is seeing a burgeoning of baby boomers (32-million) unaffiliated with a church who are buying books and magazines that cater to new age philosophies and ancient practices. There is growing interest in Eastern and Greek mythologies and finding spiritual fulfillment through poetry, music, literature, art and nature (Betensky, 2001; Blue & Darou, 2002;
Case & Dalley, 1992; McCormick, 1996).
The use of yoga and meditation have become big business and they are fueling re- interest in some of the ancient arts such as Chinese medicine, acupuncture, homeopathy, shamanism, healing hands, massage and stone therapies as a way to clear the mind and heart and to find tranquility (Smolan et al, 1993). There are now a greater number of ways that individuals can nurture themselves without going through religious channels although meditation is still considered to be one of the oldest and most beneficial practices (Walsh, 1990a, 1990b, 1999a, 1999b).
A mature understanding of human health recognizes that the spiritual aspect of existence should be acknowledged and spiritual resources mobilized. In both the etiology and treatment of eating disorders there is evidence to suggest that religious and spiritual topics can be useful to individuals who are struggling with a search for meaning, a desire for recognition and perfection, and a spiritual hunger inside themselves that cannot be filled. Therapeutic interventions that have a spiritual focus are proving to be helpful
(Lelwica, 1999).
89
Meditation and yoga have been found to be beneficial in the eating disorder program at Children and Women’s Hospital here in Vancouver, by increasing a sense of awareness, helping individuals cope with stress, and making them feel better about themselves (Manley& Leichner, 2003). These are complimented by art therapy, play therapy, support groups, family therapy and psycho-educational workshops. There is also a proliferation of visualization, biofeedback and hypnosis books and tapes which can help still the mind, ease pain and tension in the body, and prevent and treat different ailments such as headaches, pain, anxiety, panic attacks, depression, heart disease and psychological disorders (Pelletier, 1995).
A New Definition of Spirituality
The term spirituality is sometimes vague unless it is wedded to some doctrinal or ideological framework. Otto (1957) described spirituality as an experience of the numinous containing three components which he designated with a Latin phrase – mysterium, tremendum et fascinans. Mysterium - the “wholly other” - evokes a reaction of cowed silence because it is entirely different from anything we experience in ordinary life. Mysterium tremendum provokes abject terror because it presents itself as overwhelming power. And Fascinans is merciful and gracious. Otto believed that these concepts underlie all religion.
Being spirited can be based on a belief in God and way of life that involves devotion, worship, prayer and ritual depending on the individual’s belief system and the organizations to which they belong. For others it may be more about a code of behaviour rather than the participation in religious practices. A review of religious attitudes in North
90
America and the United Kingdom has shown that many more people express a belief in
God than belong to a church or organization (McIllmurray et al, 2003).
Furthermore, definitions of spirituality may also include ethical, moral and ecological issues, the meaning and purpose of human existence, and the responsibilities humans have for each other and the world around them (McIllmurray, 2003). Being spiritual can also mean having personal conversations with God, meditating on the wonders of the universe, being in communion with nature, and being the best wife/husband, mother/father, sister/brother/partner and/or friend one can be.
Discussing spirituality within the context of defining religion becomes difficult because religion can have a different meaning for different people. Religious practice is no longer the bastion against adversity that it once was yet many people associate spirituality with organized religion (Gambone, 2003). Elucidating spirituality without an academic or pedagogical framework can be equally problematic because spirituality is an abstract concept which is impossible to quantify with precision. The root of the word is spirit and in Hebrew it means alive, breath and engaged (Hull, 2001). Hull (2002) suggested that the spiritual is that which transcends the biological but I find this a simplistic definition of a very complex subject.
Although spiritual awakening is stirred through cognitive, sensory and empirical data of the natural world, Otto (1957) suggested that “… it [spiritual awakening] begins with a naïve immediacy of reaction, disengages itself from this and takes a stand in absolute contrast to it.” (p. 113). This spiritual awakening becomes interpretations, valuations, beliefs and feelings qualitatively different from sense perceptions because they
91
supplement and transcend perceptual data (Otto). The predisposition of the human spirit which awakens when aroused is this hidden source of growth.
The intent in this project is to use the broader definition of spirituality which includes living with integrity and authenticity and being involved in activities that demonstrate compassion and caring for oneself, for individuals in one’s support system and the larger society. A holistic spirituality can integrate science, psychology, religion and also embrace God. Based on this broader definition, health care professionals have an ethical obligation to help the people they serve address their spiritual needs by incorporating a spiritual component into a treatment plan. Particularly, they should help people without established ties to a faith community locate spiritual resources that meet their needs. The purpose being to offer spiritual support that respects where the person is at in their spiritual journey, rather than force a specific spiritual position or belief on anyone.
Leichner, Brown, Atkinson, Henderson and Jacek (2001) suggested that a Bio-Psycho-
Social-Spiritual model has not been seriously applied to the area of eating disorders.
Considering all of the above, it seems to me that defining spirituality within a specific faith or perspective should be avoided. Feeling the Spirit is not a force outside, but rather an intrinsic characteristic that becomes manifest from within as a feeling of the numinous (Hull, 2001, 2002, 2003; Jung, 1973; as cited in Corsini & Wedding, 2000;
Otto, 1957). Otto described this numinous feeling as being qualitatively different from natural sense perception which forms the deepest foundation that the soul possesses. In view of the centrality of spiritual experience in the lives of so many people who are dealing with major health crises, and the growing evidence that individuals derive support from their spiritual beliefs and practices, the key question would appear to be –
92
How to incorporate spiritual resources into individual lives that best meet their needs?
(McIllmurray et al., 2003; Roff & Parker, 2003).
The Role of Faith
Faith is a unique faculty for understanding truth that relies on both the rational and irrational cognitive faculties Faith also relies on individuals’ emotional faculties that are within the reach of consciousness yet beyond the grasp of comprehension. Otto (1957) stated that “Faith is like the ‘synteresis’ in the theory of knowledge of the mystics, … the
“inward teacher” (magister internus) of Augustine, …and the “inward light” of the
Quakers…” where “…… the absolute exceeds our power to comprehend; the mysterious wholly eludes it.” (pp. 138-141).
In this Canadian multicultural society, many individuals take their faith seriously and health care professionals should take this into account in their work with people facing many of life’s deepest issues. Many people find strength in their spiritual beliefs, and faith communities are natural sources of social support and fellowship in the face of challenging illness. A growing body of research evidence underscores the importance of spirituality, religiousness and faith in dealing with chronic or terminal disease (Erricker,
2002; Gambone, 2003; Hull, 2001, 2002, 2003; Otto, 1957; Walsh, 1990a, 1990b, 1993,
1999a, 1999b, 2000).
Faith is an essential component because it encourages individuals to more fully express the truth and also calls forth the truth of others. People generally recognize, admire and respect conviction that is free of artifice. Faith is a quiet source of authority that often compels people to voice their opinion and to act with purpose and meaning.
Practicing faith can also generate moments of peace and solitude within that allow
93
individuals to reflect on their actions and analyze the degree to which they resonate with their inner sense of truth. Faith encourages people to take risks that their ego and rational mind view with suspicion because of the unknowable quality of the outcome (Michalec,
2002; Roff & Parker, 2003).
Otto (1957) suggested that it is faith that generates “…… a mighty creative thing
…… that transforms us inwardly and brings us forth anew.” He described it as the mutatis mutandis or amor mysticus for the early mystics that equates to our current understanding of knowledge and love (p. 104). Faith contains patterns, rhythms and principles that should never be completely managed yet, if the small voice of the soul is listened to, it can facilitate the formation of communion with others and reassure them that the answers to questions will be forthcoming. Otto also said that “…… although all our knowledge begins with experience, it by no means follows that all arises out of experience.” (p. 112).
Faith can transform fears and uncertainties from tormentors into advisors to facilitate growth and more effective communication and it can give individuals the courage to speak from the heart and to feel that there is something at work beyond knowing (Merton,
1958). Faith sustains reflective encounters with subject matter and community, ferrets out answers to challenges and is never anecdotal to personal struggle (Merton). For me, faith forms the foundation that allows an individual to be more grounded and truthful because it allows one to be more authentic and accountable.
Sometimes being fully present means revealing aspects of personal beliefs and values, unmasking personal demons, standing publicly exposed and vulnerable. At these times faith can be a steadying hand and can sustain someone through personal and
94
interpersonal moments of doubt and uncertainty. Faith can help individuals to display a greater sense of integrity because it provides the courage to be real and it is the solid ground upon which experiences can reveal some notion of truth (Gambone, 2003).
Faith also allows individuals to be more authentic by exposing the real me instead of the pseudo self of who someone thinks they need to be or who another person thinks they should be. Like Gambone (2003) suggested, the more I act from internal faith rather than external ego, the more I am convinced of my right actions, the less likely I am to be swayed by the pressures of an academic community that would mould me into an appropriate professional image. Although others may not necessarily accept my vision of truth, hopefully they will recognize a sincere and honest expression of who I am and what
I know (Gambone).
The Value of Truth
Merton (1958) argued that one route to greater spirituality, or deeper levels of self- discovery, is to live life in a spiritual way every day. Instead of running away from the uncertainties of life, he suggested plunging in and living life soulfully. The intent being to create a situation of being fully present, fully open to another person’s values and beliefs and striving for a milieu within which there is little difference between what another person sees, and what is held internally as truth. Unfortunately, there is sometimes tension between an individual and the communal view of truth and often a struggle between humble and authoritative speech about the nature of truth (Hull, 2003).
Individuals can be encouraged to see that the more that they divulge their inner sense of truth, the more others will see them as genuine where they will be inclined to divulge their own authentic being and view of truth. Truth can also cultivate a spiritual dimension
95
fostered by community as a sacred space where individuals are willing to learn from each other (Merton, 1958, Otto, 1957; Roff & Parker, 2003). People working to impact society must be motivated by a set of deep personal values and beliefs.
When the true spiritual dimension is honoured, it suspends initial judgement of who the other person is and attempts to look past the latest fashions, dyed hair, sloppy thinking or the blind acceptance of authority. Honouring this spiritual dimension in each individual is a way to struggle against the voice of culture or Academia that seeks to categorize or stereotype according to dress, social class, academic discipline or intellectual performance. All the social and cultural accoutrements are overlooked to find the individual’s ground of being and to join them in relationship. The process values difference and diversity and seeks to understand without the intent to manipulate others for personal gain.
Vogler (1993) suggested that therapists differ in their approach to eating disorders depending on their philosophy of life, their theoretical training, and their notion of eating disorders itself. Using a constructivist exercise Dickerson and Zimmerman (1995) used the following three categories to help clarify the ways in which therapist might view the problems of eating disordered individuals: (a) As a diagnosis using the framework of the
DSM-IV; (b) as patterns in a conversation process between therapist and client; and (c) as cultural and personal discourse that influence others in ways that promote the development of problem stories. These previous categories are used to emphasize that the way the problems or issues are viewed will often dictate how the therapist approaches intervention.
96
At one end of the spectrum in more traditional verbal therapies therapists may want to act to solve, rescue, get the bingeing or purging under control, or make the patient gain weight which can push the therapist into a battle for control. Other therapists may feel an added pressure to act because of the life threatening dangers inherent in a failure to act fast enough (Vogler, 1993). In some research it has been found that anorexia nervosa clients generate more anger, stress and feelings of helplessness in psychiatric residents
(Brotman, Stern & Herzog (1984). Fleming and Szmukler (1992) found that eating disorder patients evoked more mistrust and even hostility in medical students through their perceived lying, deception and sense of arrogance and privilege than diabetics or obese individuals.
Vogler (1993) said it well when he suggested that “… the crux of the interaction is that therapists must trust and have faith in the eating disordered client if they are to trust us.” (p. 5). Resistance, deception, secretiveness, or lack of motivation should not be viewed as oppositional behaviour but as a deep fear of change, helplessness and a lack of basic trust and faith (Vandereycken and Meermann, 1987). If the sense of integrity and vision of truth held by each person is valued, then it legitimizes and acknowledges that each person embodies a unique vision of truth (Hull, 2003). Our own sense of truth is enhanced by listening clearly to the views of others reporting from unique vantage points.
Meaning-making becomes communal rather than insular and occurs in relationship with, as opposed to isolation from, others (Hull).
The Power of Forgiveness
In many different kinds of addiction interventions helping individuals to understand the concept of forgiveness towards themselves, parents, abusers and others is found to be
97
helpful in psychoeducational therapy and the healing process (Richards et al., 1997).
Encouraging individuals to be more open, compassionate and caring (particularly towards themselves) and showing them ways to honour themselves and others can be a source of inspiration. Hardman and Berrett (2001) found deep spiritual struggles to be a major factor in recovery, with many of their patients being conflicted with intense emotions, inner turmoil and issues around trust. Eating disordered individuals become accustomed to lying, covering up, secrecy and deception that eats away at their self-esteem. Many are filled with shame, and remorse for the way they have lied and hurt their families, and many of them suffer from enormous guilt for failing to live up to their own expectations of a truthful person Hardman & Berrett). There is inner turmoil around broken promises to family and friends (Hardman & Berrett).
The goals of forgiveness are to help individuals find the capacity to love themselves and others more deeply and to encourage them to have faith in themselves and trust their instincts (Mosak, 2000). There is some debate within the research community as to the degree that intellectual insight can be translated into emotional insight with this population because life is reduced to caloric awareness and blinkered vision with a narrow focus on food (Ansbacher, 1990; Watts, 1996). However, there are others who believe that there is always something sustaining that can be learned but that it takes personal responsibility and accountability to make it happen (Manley & Leichner).
Limitations of a Spiritual Approach
There is controversy around the understanding of spirituality and the role it should play in psychotherapy. Some researchers consider spirituality as good for an individual’s health which should be encouraged, while others believe that it has no scientific merit.
98
However, Otto (1957) argued persuasively that everything we know and understand cannot easily be explained by science and that there needs to be room for an intuitive component.
It is also questionable whether eating disorders can truly be understood by adopting a more scientific or qualitative approach given the complexity and uniqueness of human experience. Some researchers would argue that a spiritual focus is tantamount to crystal ball gazing while others would view this area of inquiry as crossing ethical lines because the private realm of an individual’s core belief system lies outside the boundaries of psychotherapeutic practice. An eating disorder is rarely about food and food avoidance is usually the expression of a much bigger problem that is life threatening.
Spiritual Themes in Eating Disorders
Listed below are most of the common religious and spiritual themes that came to light from the literature review (Hardman & Berrett, 2001; Lelwica, 1999; Manley &
Leichner, 2003; Pipher, 1994):
A negative perception of God;
A pervasive sense of loss;
Perfection, purity and self-sacrifice;
Feelings of unworthiness or shame;
Fear of abandonment or disapproval;
Feelings of guilt or shame around dishonesty or deceitfulness;
Difficulty in trusting or experiencing faith;
Feelings of guilt, shame or confusion around sexuality;
Feelings of disconnection, hopelessness and helplessness;
99
Forgiveness.
This chapter highlighted the importance of spirituality in the lives of individuals and put forward a more holistic definition of what it means to be a spiritual person. Exploring the historical connections and the cultural differences between Aboriginal, Asian and
Western understandings of spirituality helps to explain some of the underlying philosophical reasons why nurturing spirituality may play a greater or lesser role in individual’s lives. It may also explain why developing and nurturing spirituality is seen as being of greater or lesser importance by health care professionals in determining a hierarchy of needs to be dealt with in therapeutic interventions.
Examining how Christian beliefs and values have impacted the lives of eating disordered individuals over the ages provided a context for understanding the role that eating disorders may have played related to a spiritual life in medieval times, and the very different role it plays in individuals’ lives today. Particularly, how the human body has become a crucial subject embedded in the views and norms of the Western psyche.
The chapter also discussed the burgeoning interest in the search for a more spiritual life and the quest for greater spiritual fulfillment through ancient practices and new age philosophies. The discussion provided a new and expanded definition of what it means to be spiritual and how to incorporate spiritual resources into individuals’ lives. In considering the role of faith, truth, and forgiveness it provided a context for understanding why these topics are important, how the understanding of these issues affect how individuals are helped, and the limitations of using a spiritual approach in psychotherapy. In conclusion, the chapter highlighted the spiritual themes that would be relevant to include in working with an eating disorder population.
100
The evidence would seem to suggest that it is important for the care plan to build on strengths in an individual’s faith tradition to attempt to address unmet spiritual needs. By expanding the definition of spirituality into a more holistic concept that includes God, religion and science it would seem to offer more inclusive, comprehensive and holistic therapeutic possibilities. As ethical practitioners it behoves us to provide inexpensive and thoughtful ways that psychotherapeutic interventions can be offered to this population.
The intent in this project would be to reorient these adolescents to more realistic goals of life and away from unattainable goals of security and mistaken perceptions of the demands they place on themselves and others. Developing a spiritual approach to life can also help to replace feelings of low self-worth with greater self-esteem, sense of accomplishment and self-awareness (Ansbacher, 1990; Arlow, 2000; Watts, 1996).
Examining the information above, there is room for spirituality, religion and science to be included in a rich and fertile therapeutic environment. Learning to acknowledge that humans and human existence is flawed, that there is no such thing as perfection, can help to build better personal relationships and collaborative goals. Examining the eating disorder literature in the next chapter will highlight why this approach may be more supportive for this population.
101
CHAPTER VI
Literature Review – Eating Disorders
The following topics will be reviewed in this chapter beginning with prognosis, recovery, mortality and age of onset. Research on co-morbid factors, other substance use, risk of suicide, and the impact of social isolation is highlighted. It also provides an historical overview of the changes that have occurred over the last twenty five years with respect to diagnosis, etiology, treatment and the use of medications. This information is important and relevant for providing a context around understanding eating disorders and some of the precipitating factors that may contribute to the development of the condition.
What are Eating Disorders?
Eating disorders are multi-faceted and multi-layered illnesses which often begin during childhood or adolescence (Manley, Rickson & Standeven, 2000; Pinzon & Jones,
2003). In North America the span of adolescence begins roughly between ten (10) and thirteen (13) years of age and ends at eighteen (18) to twenty (20) years of age. For the purposes of clarification both the term adolescent and teenager will be used interchangeably because some Asian cultures have difficulty in recognizing the word adolescent.
Prognosis
It is estimated that a half percent (0.5%) of adolescent females in North America have anorexia nervosa, one (1%) to five (5%) percent meet criteria for bulimia nervosa, and only five (5%) to ten (10%) percent of all cases occur in males. A large number of individuals with milder cases do not meet all of the criteria for an eating disorder but
102
experience the physical and psychological symptoms of having one (American Academy of Pediatrics, 2003).
Recovery
Longer term follow up studies indicate between fifty-eight (58%) and eighty-six
(86%) percent recover or have good or satisfactory outcome with treatment (Bryant-
Waugh, Knibbs, Fosson, Kaminski & Lask, 1988; Herpetz-Dahlmann, Wewetzer, Schulz
& Remschmidt, 1996; Kreipe, 1989). Today, recovery is possible for about seventy-six
(76%) of individuals with anorexia nervosa, although the median length of time to recovery is approximately six to seven years (Strober et al, 1997; as cited in Manley &
Leichner, 2003). The recovery process is less clear for individuals suffering from bulimia nervosa, although there are encouraging results with adults receiving cognitive- behavioural or interpersonal psychotherapies (Fairburn, Norman, Welsh, O’Conner, Doll
& Peveler, 1995; Wilson, Fairburn & Agras, 1997).
Mortality
Mortality increases in individuals with a late age of onset, a long duration of illness and severe weight loss. Steinhausen, Boyadjieva, Griuogotuiu-Serbanescu and
Neumarker (2003) suggested that approximately forty-four percent (44%) recover, twenty-five percent (25%) remain seriously ill, and five to six percent (5% to 6%) die.
Sullivan (1995) suggested that mortality rates are as high as twenty percent (20%) in chronically ill adults with Anorexia Nervosa. Major concern is raised because of the multiple medical complications that can arise due to severe chronic starvation (AlAteeqi
& Allard, 2001; American Psychiatric Association, 1994, Manley & Leichner, 2003;
Pinzon & Jones, 2003).
103
Age of Onset
Much of the anecdotal evidence also indicates that the age of onset is becoming younger although there are few population-based studies specifically aimed at young children. However, surveys of dieting and body dissatisfaction in children suggest that preoccupation with body weight and body image at a younger age is a problem.
Depending on the study, between twenty percent (20%) and forty-two percent (42%) of nine year old girls were trying to lose weight and fifty-five percent (55%) of girls between the ages of eight (8) and ten (10) were dissatisfied with their size. Of even greater concern is that approximately twenty-one percent (21%) of five year old girls had weight concerns (Nicholls, Chater & Lask, 2000; Pipher, 1994; Robin, Gilroy & Dennis,
1998).
Food Avoidance Tactics
In doing meal support with eating disordered individuals they can use quite sophisticated food avoidance tactics by claiming that they have allergies, intolerance of certain foods or physical ailments that prevent them from eating certain quantities and types of foods. These adolescents can become obsessive with caloric intake, anxiety provoked at the thought of consuming fat content, and they tend to obsessively read information on all food labels related to calories. Even when their nutritional intake is being monitored, eating disordered individuals can resort to carrying weights or water logging their bodies by drinking before weighing to appear heavier.
Often eating disordered individuals perseverate about their body shape sometimes in odd places like the collar bone, calves, wrists as well as the more obvious stomach and thighs. These adolescents often weigh themselves constantly. Sometimes it is hard for
104
other people to understand how some individuals suffering from an eating disorder go undetected for so long but they become masters of disguise, hiding their body shape beneath layers of clothing and becoming closet eaters and exercisers (Kirkpatrick &
Caldwell, 2001).
Increased Risk of Suicide
Suicide is a risk factor in the adult population (Surgenor & Snell, 1998), and in a meta-analysis of suicide in a range of mental disorders, it is reported that with adult anorexia nervosa individuals the risk increases twenty-three (23%) percent (Harris &
Barraclough, 1997). Data on the risks of suicide in the adolescent populations does not appear to be available at this time (Fisher et al., 1995; Manley & Leichner, 2003).
Co-morbid Psychiatric Illnesses
High rates of co-morbid psychiatric illness are reported in studies of adolescents and adults. For example diagnosis of anxiety disorders was reported in approximately fifty- six percent (56%) of adolescents with the onset of anorexia nervosa, sixty-six percent
(66%) of adolescent females were diagnosed with a major depressive or dysthymic disorder (Herpetz-Dahlmann, Muller & Herpetz, 2001). Anti-depressants which include tricyclic antidepressants, monoamine oxidase inhibitors, and serotonin re-uptake inhibitors such as prozac and paxil are used widely. Antipsychotic medications such as lithium, appetite stimulants, anticonvulsants as well as neuroleptics to control bizarre eating patterns, behaviours and delusional manifestations are also used (Zerbe, 1995).
Therefore, it is not uncommon for some individuals to also have chemical dependency and other maladaptive behaviours.
105
Pipher (1994) suggested that more adolescents are finding their way to her office with eating disorders compounded by alcohol problems, posttraumatic stress reactions to physical or sexual assaults, sexually transmitted diseases (STDs), self-inflicted injuries and strange phobias. She quotes statistics from a Midwestern American city as being up by forty percent (40%) in 1993, and in Atlanta suicide rates among children aged ten to fourteen rose seventy-five percent (75%) between 1979 and 1988 (Centres for Disease
Control in Atlanta; as cited in Pipher).
Increased Social Isolation
Manley and Leichner (2003) suggested that profound psychic pain is associated with increased social isolation fueled by the debilitating effects of chronic starvation and the relentless pursuit of thinness. Teenagers with an eating disorder can suffer from self- loathing and participate in self-punishing behaviours such as over-exercising and suicide attempts brought on by profound anguish and despair (Manley & Standish, 2005). These young people also often have a sense of being out of control and suffer from feelings of hopelessness and helpless (Kuehnel, 1998; Lelwica, 1999; Manley & Leichner).
Other Substance Use
Some research has found an association between problem weight loss behaviours and other risky substance use such as alcohol, drugs and cigarettes. One study that examined four-hundred and twenty-four (424) middle school girls (African American and European ancestry) for predictors of weight control behaviours found substance use was one significant predictor (Barr et al., 1998). Among high school students it was found that thirty-nine percent (39%) of European ancestry females used cigarettes as a way to control their appetite and weight (Camp, Klesges & Relyea, 1993). While the results of
106
this research should be treated with caution, it does suggest that disordered eating behaviours and substance use may be part of a syndrome that should be taken into account when providing preventive care services.
An Historical Overview
Themes of self-denial, asceticism and abstinence are common to many religions and cultures. Less extreme purification practices of the body and soul through rituals involving fasting or food avoidance are part of the normal religious life in many cultures
– Lent and Ramadan are just two that come to mind. Spiritual cleansing was (and still is) seen as a way to purify oneself in the eyes of God, to acknowledge and humble oneself in the presence of an omnipotent being, and as a way to guarantee a place in the Hereafter.
Holy men and monks, many who are legend or revered within their culture, use fasting to reach higher or altered states of consciousness. These types of practices are highly regarded in many religions and cultures that value spiritual health (Lelwica, 1999).
Preparing and eating food today is still an important social ritual where love for family and friends is expressed through the preparation of special meals and rituals such as birthdays, and traditional thanksgiving and Christmas dinners that celebrate our most important relationships (Kirkpatrick & Caldwell, 2001). Lelwica (1999) argued that the
North American culture breeds a spiritual hunger in a consumer driven society. Lelwica
(1999) and Kilbourne (1999) suggested that we live in a sick society where the emphasis on superficial beauty and being thin has reached cult proportions in the quest to stay young and look good. We are more knowledgeable than ever before about what constitutes healthy eating and a healthy lifestyle yet we have more children, adolescents and adults suffering from obesity, eating disorders and risk-taking behaviours. Friedman
107
(1997) suggested that in a patriarchal culture with emphasis on competition, consumerism, independence and detachment, the qualities of consideration, cooperation, and nurturance have been relegated to a back seat.
Changes Over the last Twenty Five Years
Diagnosis
Over the past twenty five years there have been dramatic changes related to the diagnosis, etiology and treatment approaches of eating disorders. Previously, eating disorders were diagnosed by exclusion, considered to be definitive and categorical and thought to be very rare. Today the diagnosis is by interview with individuals and their families and considered on a continuum. Categories of the disease are specified, as well as a breakdown of men and women sufferers using statistical understanding of the various conditions (Nicholls, Chater & Lask, 2000; Robin, Gilroy & Dennis, 1998).
Etiology
In the past the condition was thought to be uni-factorial related to biological, analytical or behavioural factors within a culturally-bound syndrome, a mind and body split, and little awareness of past traumatic experiences related to childhood or family of origin. Today the etiology is considered to be multi-factorial and the approach uses a Bio-
Psycho-Social model that considers cultural, social and political elements. The emphasis is more on a mind and body connection, and includes relevant traumatic childhood or past experiences related to family (Fisher, Goldman, Katzman, Kreipe, Rees,
Schebendach, Sigman, Ammerman & Hoberman, 1995; Manley & Leichner, 2003;
Manley, Rickson & Standeven, 2000). Some successful approaches to therapeutic
108
interventions include a spiritual element but they are often tied to a biblically based approach (Remuda Ranch Programs for Anorexia and Bulimia Inc, 2005).
Treatment
Treatment options have burgeoned from using a uni-disciplinary, uni-model approach where a medical or psychiatric inpatient/outpatient approach was used, to a multi- disciplinary one using multi-modal criteria. Various options for treatment are now included such as inpatient, day program, outpatient, case management and transition homes. In the past there were no group treatments, little family therapy or client/family education, strict behavioural treatments including forced tube feeding, significant use of certification and classical psychoanalytic treatment, and no self-help options (Fisher et al., 1995; Le Grange & Lock, 2004).
Nowadays, emphasis is placed on group therapies, family therapy for younger clients, psychoeducation groups for individuals, families and friends, less stringent behavioural tactics, meal support and little use of tube feeding. Certification is rarely used and there are a variety of intervention options including cognitive behavioural, psychodynamic, interpersonal, motivational enhancement, narrative, solution-focused, client-centred, art therapy and experiential approaches. Self-help is now actively encouraged as being the crux of the recovery process (Fisher et al, 1995; Manley & Leichner, 2003; Manley,
Rickson & Standeven, 2000; Manley, Smye & Srikameswaran, 2001).
Medications
Twenty-five years ago all medications were used, the prognosis was poor, the mortality was around twenty-five percent (25%), and the disorder was considered incurable. Today prognosis is good, the mortality rate has dropped to around six percent
109
(6%), and it is seen as curable. There is also the belief that if the disorders are recognized and treated early in the cycle and at a younger age, there is a better chance for recovery
(Manley, Rickson & Standeven, 2000). Now the understanding of drugs is much more comprehensive with the result that drugs (if they are used at all) are more controlled and targeted to a specific symptom. For most adolescents, the longer term effects of medication are not so well understood, so their use is given extra consideration by most family physicians and psychiatric doctors (Fisher et al., 1995; Manley, Rickson &
Standeven).
What has not changed over the last twenty-five years is violence towards women and children and there is still a stigma against mental illness. Prevention programs suffer from budgetary constraints, and there are still insufficient mental health care resources that strive for excellence. Related to prevention programs there are also more professional barriers that can lead to turf wars or entrenched, dogmatic thinking. On the plus side, there has been increased professional and public awareness, increased research and understanding of the factors involved, and more educational opportunities. Specific allocation of funding for a range of services across Canada has also meant increased ethical clinical practice (Lelwica, 1999; Pipher, 1994).
This section was helpful in understanding what it means to suffer from an eating disorder. Highlighting the evolution of how the diagnosis, etiology and treatment of eating disorder has changed over the last twenty five years provides a context within which to grasp the extremely complex and multifaceted nature of this disorder including comorbid factors, other substance abuse and increased risk of suicide. The following section discusses the diagnostic process for classifying an eating disorder.
110
CHAPTER VI
Literature Review – Eating Disorders
Details on the DSM-IV criteria for diagnosing three classifications of eating disorders are outlined in this section plus the serious developmental risk factors. Also included is an alternative classification given that the DSM-IV may not fit the criteria for children and adolescents. Understanding the DSM-IV criteria is helpful for facilitators to be alert to asking questions during intake that can help in properly identifying and assessing
Anorexia Nervosa, Bulimia Nervosa and other eating disorders not specified. It can also be helpful in diagnosing the degree that other comorbid factors may be influencing the condition, or conversely, be influenced by the disease.
The DSM-IV can also be used to measure pre and post change by having clients identify behaviours that they did before and after completion of the group. Furthermore, many clients may benefit from being told the criteria that categorizes their condition and be relieved to have information that provides clarity around a diagnosis. Understanding the developmental risk factors is critical for the facilitator to understand the importance of providing physical and psychological safety within the group program.
The Diagnostic and Statistical Manual of Mental Disorders Criteria
The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), (American
Psychiatric Association, (APA), 1994), used by the medical community in mental health and treatment, describes eating disorders as self-destructive and potentially life- threatening behaviours. The manual includes Anorexia Nervosa, Bulimia Nervosa or eating disorders not otherwise specified (individuals fulfilling some, but not all, of the diagnostic criteria for either anorexia nervosa or bulimia nervosa).
111
DSM-IV Criteria – Anorexia Nervosa
Refusal to maintain body weight greater than eighty five percent (<85% for age and
Height);
Intense fear of weight gain or becoming fat, even although underweight;
Disturbance in the way in which body weight, size or shape is experienced;
Undue influence of body weight or shape on self-evaluation;
Amenorrhoea for at least three (3) consecutive cycles in post-menarchal females
(secondary amenorrhoea).
Restricting types. No regular bingeing or purging.
Binge eating/purging types. Regular bingeing and purging (APA, 1994).
DSM-IV Criteria – Bulimia Nervosa
Bingeing and purging episodes where copious amounts of food are eaten (binge) and
then disgorged (purged) either through vomiting or the use of laxatives or diuretics
over a relatively short period of time (i.e. 2 hours), and more than would be eaten by
most people in similar circumstances.
Recurrent inappropriate compensatory behaviour to prevent weight gain such as self-
induced vomiting, fasting, hyper-exercising, use of laxatives/diuretics.
Binges or inappropriate compensatory behaviours occur on average at least twice
weekly for at least 3 months.
The disturbance does not occur exclusively during episodes of anorexia nervosa.
Purging types. Regularly engages in self-induced vomiting or use of laxatives/diuretics.
112
Non-purging types. Uses other inappropriate compensatory behaviours such as fasting or hyper-exercising, without regular use of vomiting or medications to (APA, 1994).
DSM-IV Criteria - Eating Disorders Not Otherwise Specified
All criteria for anorexia nervosa, except regular menses.
All criteria for anorexia nervosa, except weight still in normal range.
All criteria for bulimia nervosa except binges twice a week or 3 times a month.
Individual with normal body weight who regularly engages in inappropriate
compensatory behaviour after eating small amounts of food (i.e. self-induced
vomiting after eating 2 cookies for example).
Individual who repeatedly chews and spits out large amounts of food without
swallowing.
Binge eating disorder: recurring binges but does not engage in the inappropriate compensatory behaviours of bulimia nervosa (American Psychiatric Association, 1994).
The role of the DSM-IV is of considerable concern and continues to be called into question because some studies have shown that the criteria stipulated above may not be a developmentally appropriate measure for children or young adults (particularly the use of primary amenorrhoea related to menstrual cycles), (Nicholls, Chater & Lask, 2000). A recent study has demonstrated that even older adolescents have poor perception of their actual body size and younger adolescents have such a varied developmental presentation in terms of such things as amenorrhoea (Nicholls et al.). As will be discussed later there is also some question around the way eating disorders manifest in younger adults.
Given these kinds of concerns, it is important to understand that the current diagnostic criteria for children and adolescents may not fit the DSM-IV criteria described here
113
because the available clinical and research literature used to develop these criteria have primarily focused on older adolescents or adults (Nicholls et al.). Manley, Smye and
Srikameswaran (2001) argued that current research evidence suggests that there is a wider range of eating disturbances among the younger population that may not be linked to eating difficulties or a fear of gaining weight. There are also developmental factors to consider that may affect the conceptualization or function that the eating disorder serves for the individual that may change over time (Manley, Smye & Srikameswaran).
DSM-IV - Developmental Risks
During adolescence, added concern is given to the developmentally sensitive process occurring at this time of irreversible physical, emotional and psychological affects. The medical complications include growth retardation, pubertal delay or arrest, impaired acquisition of peak bone mass increasing the risk of osteoperosis in adulthood (Fisher et al. 1995), and the risk of generalized and occasional regional atrophy of the brain (le
Grange & Lock, 2005). Eating disorders are also associated with poor social functioning
(Katzman, Christensen, Young & Zipursky, 2001), low self-esteem (Pipher, 1994), high rates of comorbid substance abuse, mood disorders, anxiety disorders and personality disorders (Fisher et al., 1995; Wonderlick & Mitchell, 1997). Adolescents struggling with these disorders often experience cognitive distortions related to body image, obsessive thoughts and behaviours involving food, binge eating and purging behaviours, and relationship difficulties (Manley, Rickson & Standeven, 2000; Pinzon & Jones, 2003).
An Alternative Classification - Great Ormond Street Criterion
Robin, Gilroy and Dennis (1998) have suggested that up to fifty percent (50%) of children and adolescents referred to an eating disorder clinic may not fit the current
114
diagnostic criteria for anorexia nervosa or bulimia nervosa. And given that linguistic and cognitive development are developing in tandem at this age, adolescents may be unable to express distress in terms of body shape or self-perception but may instead experience and describe symptomatic symptoms in terms of physical pain or discomfort, feelings of fullness, nausea or loss of appetite.
An alternative classification for the range of eating disorders of childhood proposed by Lask and Bryant-Waugh (1995) is the Great Ormond Street (GOS) criteria. The diagnoses within this classification are anorexia nervosa, bulimia nervosa, food avoidant emotional disorder, selective eating, functional dysphagia, and pervasive refusal syndrome. The overriding feature of all these diagnoses is the excessive preoccupation with weight or shape and/or food intake which is accompanied by grossly inadequate, irregular or chaotic food intake (Lask & Waugh). Fisher et al., (1995) and Robin, Gilroy and Dennis (1998) suggested that while the classification of eating disorders in children still needs evaluation, the GOS criteria may be more reliable than the existing DSM-IV.
This chapter was helpful in understanding the DSM-IV criteria and the physical and psychological differences between the diagnosis of Anorexia Nervosa, Bulimia Nervosa and Eating Disorders Not Specified. Using the more inclusive alternative classification for diagnosing eating disorders supports a broader range of eating disorders that may be more relevant to children and adolescents. The following two sections expand on the understanding of Anorexia Nervosa and Bulimia Nervosa.
115
CHAPTER VI
Literature Review – Eating Disorders
In the following two sections Anorexia Nervosa and Bulimia Nervosa are described separately so that the reader can understand more clearly the differences between the presentation of the disorders and the different, yet equally serious, medical implications of Anorexia Nervosa as opposed to Bulimia Nervosa. This information is important because it can help the facilitator identify simple yet different physical and psychological signs of the presenting disorder and alert them to asking strategic question during intake interviews that will properly assess the presenting disorder.
Anorexia Nervosa
Although the exact cause of anorexia nervosa is unknown, the Bio-Psycho-Social model is widely accepted. Anorexia Nervosa is an eating disorder characterized by a morbid fear of gaining weight and the loss of desire for eating (Le Grange & Lock, 2005;
Pinzon & Jones, 2003). The word anorexia comes from the Greek an meaning not and
Orexis meaning desire. The word nervosa comes from the French word nerveaux which is related to the nervous system, implying a psychologically based fear of gaining weight
(Sandy, 1998).
Anorexia nervosa has two sub-types (restricting) and (bingeing and purging) which is important to distinguish because the two groups are known to differ in other domains such as personality (Bulik, Sullivan, Weltzin & Kaye, 1995), general psychopathology
(Kleifield, Sunday, Hurt & Halmi, 1994), and treatment engagement (Herzog et al.,
1996). Anorexia can occur in men but it most commonly occurs in young women. The
116
ratio of young females to males suffering from disordered eating is twenty to one (20>1)
(Bulic et al.).
The disorder is associated with the highest mortality of all psychiatric diseases, ranging from five to ten percent. Mortality increases in individuals with a late age of onset, a long duration of illness and severe weight loss. Major concern is raised when individuals are eighty five percent or less of their ideal body weight because of the multiple medical complications that can arise due to severe and chronic starvation
(AlAteeqi & Allard, 2001; Manley, Rickson & Standeven, 2000; Pinzon & Jones, 2003).
One of the first noticeable signs is a loss of weight and an unusually low intake of food. Odd eating habits and rituals develop around eating such as cutting up food into tiny pieces, refusing to eat with the family or eating in public. Others who appear to eat more normally will sometimes begin to exercise excessively in order to burn off calories.
One telltale sign is the appearance of Lanugo hair (a soft fluffy hair that appears all over the body) in an effort to maintain body heat (Fisher et al, 1995). Death is usually secondary to cardiovascular collapse but there can be an increase of sudden death related to bradycardia, arrhythmias and electrolyte abnormalities particularly during refeeding periods (AlAteeqi & Allard, 2001; Wonderlick & Mitchell, 1997).
Medical Implications
Starvation is a form of malnutrition as a result of prolonged deprivation of food which leads to a series of metabolic adaptations that can lead to medical complications and death (Manley, Smye & Srikameswaran, 2001; Pinzon & Jones, 2003). Starvation causes endocrine abnormalities such as loss of menstrual cycle (Amenorrhea) and hypothalamic
117
hypogonadism leads to an increased risk of infertility, impairs temperature regulation, and causes hypoglycemia, hypertension and diabetes (Pinzon & Jones).
Anorexia nervosa has an impact on the gastrointestinal tract causing abdominal bloating and constipation and pancreatic dysfunction which causes the malabsorption of nutrients, depletion of potassium, magnesium and calcium that may lead to irreversible growth failure, delayed sexual development, puberty, osteoperosis, amenorrhoea or delayed menarche (AlAteeqi & Allard, 2001; Fisher et al. 1995; Le Grange & Lock,
2005; Katzman et al., 2001; Manley, Rickson & Standeven, 2000; Pinzon & Jones,
2003).
Eating disorders can lead to dramatic fluid shifts and vitamin deficiencies that can cause anemia and a reduction in bone marrow fat. This leads to a loss of energy, impaired respiratory function, decreased vital capacity, reduced pulmonary ventilation and efficiency along with muscle wasting. The condition brings on lethargy, memory loss, dysrhythmia, confusion, nausea, vomiting, irritability, the inability to maintain body temperature which leads to health complications such as convulsions, coma and heart failure (Fisher et al., 1995, Pinzon & Jones, 2003).
118
CHAPTER VI
Literature Review - Bulimia Nervosa
Bulimia nervosa typically begins early in adolescence when young women react to failed attempts to control or restrict binge eating. Bulimia nervosa is also characterized as a behaviour where copious amounts of food may be consumed (binge) in a relatively short period of time, followed by purging the body of excess calories either by vomiting, using laxatives or diuretics accompanied by a sense of being out of control. The incidence of bulimia nervosa is approximately 1-3% percent in the older adolescent population (American Psychiatric Association, 1994). Individuals suffering from Bulimia
Nervosa often describe themselves in a binge episode as being out of control and being temporarily severed from their negative feelings and emotions (Kirkpatrick & Caldwell,
2001).
Bulimia has a hyper-concern with weight and shape, and the individual engages in recurrent compensatory behaviour to counteract perceived caloric intake (American
Psychiatric Association, 1994). The purging behaviours are usually kept secret and accompanied by feelings of shame and guilt. Bulimia can also go undetected for some time because initially the individual manages to stay within their weight range. Some research suggested that individuals usually progress on to anorexia nervosa as the condition worsens (Fisher et al., 1995; Kirkpatrick & Caldwell, 2001). The bingeing and purging episodes can average fourteen episodes per week (Kirkpatrick & Caldwell).
Bulimia has been identified by many different names in many different cultures across the centuries including bulimy (Greek), boolmot (Hebrew), ess sucht (German for craving for eating), phegedaena, hound’s appetite, canine appetite, bolilsmus, bolimos,
119
cynorexia and gluttony (Kirkpatrick & Caldwell, 2001, Sandy, 1998). The word bulimia is derived from the Greek word bous, meaning ox and limos meaning hunger (Sandy,
1998). The word nervosa comes from the French word nerveaux which is related to the nervous system implying a psychological connection (Sandy). Bulimia nervosa is directly correlated with intense fear of weight gain, body size or shape.
Medical Implications
One of the most noticeable physical signs of bulimia is puffy cheeks (called
Chipmunk cheeks) which is a symptom of the salivary glands swelling and is brought on by bingeing and purging (Kirkpatrick & Caldwell, 2001). One telltale sign is what is referred to as Russell’s sign which are scars that appear on the back of the hands caused by the teeth rubbing against the skin during purging (Blair, Robinson, Fleming, McCloy
& Mollenhauer, 1998; as cited in Sandy, 1998). Forced vomiting can rupture the esophagus or cause blistering, tearing or bleeding of the throat. Acid reflux causes dental and gum decay. As the body’s chemical and hormonal levels become imbalanced and as weight fluctuates dramatically, individuals suffer from many of the physical, psychological and medical symptoms described earlier under anorexia nervosa.
Highlighting the differences between Anorexia Nervosa and Bulimia Nervosa is helpful for recognizing some telltale psychological and physical signs of the disorders. The following section discusses the socio cultural factors associated with an eating disorder.
120
CHAPTER VI
Literature Review – Eating Disorders
This section discusses the research on the socio-cultural factors and the influence of the media, advertising and fashion industries in perpetuating these types of disorders.
These are important considerations for the facilitator and the individuals themselves to think about given the huge investments that are being made by multi-billion dollar organizations using covert and overt messages that seek to influence our thinking on our beliefs and values about beauty, good and bad foods, exercise and healthy living. In this group program, developing self-esteem, self-awareness, critical consciousness to deal with subtle (and not so subtle) media, fashion and advertising pressures is a primary focus of the psychoeducational portion of this group program.
Socio-Cultural Factors
The production of junk food and the proliferation of specialized eateries and coffee houses in North America attest to the fact that food and eating has become a multi-billion dollar business where the public is constantly being bombarded with the latest food or diet fads. Kilbourne (1999) suggested the focus on hyperthinness on the one hand and the proliferation of junk food on the other is contributing to greater obesity and more distorted eating behaviours to such an extent that she described it as a primary public health problem.
Flament et al., (2001) suggested that body dissatisfaction, dieting and other problem weight loss behaviours usually start to occur in early adolescence due to the onset of puberty, dating and associated societal and academic pressures. Studies of middle school students have reported that between thirty percent (30%) and fifty-five percent (55%) of
121
normal weight young girls have dieted at some time (Childress et al., 1993).
Approximately one third of these young girls progress to other problem dieting behaviours such as diet pills, vomiting or laxatives (Pinzon & Jones, 2003; Shisslak,
Crago & Estes, 1995; Shisslak et al., 1998).
Advertising
Food can act as an aphrodisiac, evoke a particular memory or be an emotional soother because for most people the sight, smell or taste of particular foods can trigger our deepest pleasures and our greatest fears. Advertising companies cash in on this by appealing to our pleasures and insecurities. Most people in Western cultures are also acutely aware of the prejudices against being fat and advertisers rarely miss an opportunity to tell us over and over that we can never be too thin or have too much money. We are only a pair of jeans, a gadget, cigarette, drink or chocolate bar away from utopia. Food can generate a sense of wellbeing, peace, calm or Zen or alternatively, generate fears and anxieties (Kilbourne, 1999).
Kilbourne (1999) suggested that the average North American is exposed to at least a thousand ads every day and will spend three years of their lives watching televisions commercials. Advertising makes up seventy percent (70%) of our newspapers and forty percent (40%) of everything that comes into our houses through the mail (Kilbourne).
She suggested that the advertising companies create a climate that appeals to our sense of loneliness or alienation, then proceed to sell us something as though it were a lover, partner or a relationship which we buy into in a vicious cycle.
In Deadly persuasion (1999), Kilbourne argued that children and adolescents are in even greater danger from destructive, traumatizing and unethical advertisements in the
122
name of furthering brand loyalties. Advertisers know that children and adolescents have money to spend and she makes a persuasive argument that in this consumer age, advertisers are holding everyone’s consciousness captive and feeding into empty illusions that increase the sale of addictive products such as cigarettes, liquor, fashion and diets.
Advertisements are particularly powerful and persuasive to vulnerable audiences such as children and adolescents who, even in their wildest dreams could never measure up, but they are unable to realize that this external beauty is a figment of the imagination of some advertising conglomerate who is only interested in bottom line profit margins. The sense of inadequacy intensifies the pervasive use of the most primitive and painful psychological defenses by appealing to magical omnipotence, envy and manic behaviours where individuals see themselves as not quite good enough (Kilbourne, 1999).
Kilbourne (1999) argued that the only way out is a threefold process where mental health care professionals need to educate themselves about the pervasive negative affects of the advertising industry, develop their own critical consciousness, and actively foster the development of critical being in their clients. In that way, individuals can be helped to stand back from, and question, attachments to abusive internal and external relationships.
Kilbourne (1999) is relentless in her criticism of the way that companies, motivated by profit, have raped the hearts, minds and souls of an unsuspecting public. She suggested that most advertisers are on a mission to create, intensify and exploit addictions, racism, sexism, child abuse, illness and pain. She suggested that as the toxicity of the cultural environment intensifies counsellors need to eschew managed care which promises instant gratification and transformation in favour of developing real, bonded and human relationships. To argue that ongoing relationships with real people
123
matter more than looks, or things, or addictions stands in direct contrast to the big lie of a consumer culture and puts a dent in pervasive collective cynicism.
Fashion
In the last twenty-five years social pressures for thinness aimed at women is being fueled by the fashion industry images and advertisements. Lelwica (1999) suggested that thirty years ago pop icons were ten percent (10%) thinner than the average female. Ten years ago they were twenty-three percent (23%) thinner. Today, young girls are struggling under pressure to be twenty-eight percent (28%) thinner than current pop icons. Fashion models tend to be a minimum of 5’ 10” (average person is 5’ 4”). The average weight of a fashion model is 110 pounds (average person’s weight is 144 pounds) (Lelwica).
The digital capability to cut and paste, draw and quarter facial and body parts, or the magical ability to air brush out flaws are particularly damaging and demeaning for today’s females because they are often dehumanized and sexualized in visual ads as strategic and dismembered body parts(Kilbourne, 1999). In advertisements men are often portrayed as strong and sexually virile whereas women are often portrayed in roles of subordination or domination. This portrayal feeds into the social norms that men are the more powerful sex and women are weaker and inferior.
A Cultural Link
Much of the research suggested that disordered eating has been increasing over the last fifty years and that it is now the third most common chronic illness affecting adolescent females (AlAteeqi & Allard, 2001; Fisher et al., 1995; Manley & Leichner,
2003). Other research has examined the links between eating disorders and gender and
124
race (Childress, Brewerton, Hodges & Jarrell, 1993). Although some research has suggested that there is a cultural link (Abrams et al., 1993; Story et al., 1991) other research has suggested that it cuts across these associations (Childress et al., 1993;
French, Story, Neumark-Sztainer-Downes, Reznick & Blum, 1997; Neumark-Sztainer,
Story, Falkner, Beurhring & Resnick, 1999).
Important for the reader to understand in this section is the pervasiveness and subtle pressures being put on everyone which often zero in on our worst insecurities. The discussion was helpful in understanding how advertisements that target children and adolescents are particular insidious and destructive because of childrens’ and adolescents’ limited intellectual capacity. Facilitators benefit from understanding how companies in the name of profit exploit everyone.
This section was important for considering ways in which facilitators can help individuals counteract the negative impact of the media by advocating for real raltionships rather than relying on superficial beauty, objects or addictions. This information was also helpful in showing the relevance and importance of using the psychoeducational media resource package for this population. Particularly important was helping health care professionals understand how body image ideals have changed over time and the significant pressures that the current crop of adolescents are up against in today’s society. This leads directly into the next chapter that deals with some of the pros and cons that motivate adolescents to develop an eating disorder in the first place.
125
CHAPTER VI
Literature Review – Eating Disorders
In this chapter the pros and cons associated with having an eating disorder are discussed because research suggests that eating disorders are among the most intractable of all psychological disorders due to the egosyntonic nature of some eating disorder symptoms. This ego stroking component is highly prized and valued by some individuals
(Serpell, Teasdale, Troop & Treasure, 2004; Serpell & Treasure, 2002; Serpell, Treasure,
Teasdale & Sullivan, 1999).
This information is important to understand because it highlights the differences that can exist between how the disorder is viewed by an individual with Anorexia Nervosa as opposed to Bulimia Nervosa. Knowing these differences can influence the success or failure of being able to connect and stay connected to each individual within a group program. Understanding how an individual’s beliefs and values are consciously or unconsciously held can help the facilitator ask the right questions for identifying what may be the motivating factors for that individual.
The Pros and Cons of an Eating Disorder
Some of the pros identified in individuals were that the anorexia made them feel safe and special and helped them maintain self-control over bodily functions such as their monthly period pains. The eating disorder gave them confidence when they were with other people because it made them think that there was at least one thing that they could do better than others. Individuals also described the disorder as allowing them to avoid unpleasant feelings, made them feel more attractive and fitter, and helped express inner turmoil (Serpell & Treasure).
126
The cons that were identified in this same study were that anorexia pretends to be a friend but is, in fact, an enemy. The preoccupation with food and eating begins to take over their lives, cuts them off from their own feelings so that they become more moody and irritable and it affects the quality of their most important relationships with family and friends because it prevents them from socializing. The disorder seeps into every aspect of their lives draining them physically, mentally, emotionally and spiritually to the point of exhaustion.
In a study on bulimia nervosa (BN), Serpell and Treasure (2002) found a different set of themes from those expressed by individuals with anorexia nervosa (AN). In the pros column individuals used bulimia to avoid boredom and it allowed them to eat the food they liked without gaining weight or becoming fat. On the con side individuals found that the bulimia generated feelings of shame, disgust and self-hatred and made individuals feel unattractive and unworthy of happiness. The study also found that individuals were constantly thinking obsessively about their weight, shape and about how they looked to others. One of the important differences between the two groups was that bulimia individuals found less pros and more cons to having the disorder.
Anorexia clients most commonly mentioned as pros a guardian theme followed by attractiveness, control, difference, confidence and avoidance. Whereas bulimia clients most commonly mentioned the pros of the guardian and avoiding emotions, they mentioned being able to eat and not gain weight less often. The main cons for the anorexia sample such as pretend, social health, emotions and taking over their lives were a similar concern for bulimia clients, but BN clients also rated higher for negative self- image (Serpell & Treasure, 2002).
127
The findings supported earlier studies that suggested that individuals with bulimia were more negative about their behaviours than those with anorexia, more ready to change their behaviour, and most likely to be in the action stage of change related to decisional balance (Blake, Turnbull and Treasure, 1997). Bulimia nervosa sufferers may have temperamental traits such as impulsivity (Welch & Fairburn, 1996), and novelty seeking (Brewerton, Hand & Bishop, 1993). This could mean that while the bulimia individual has high motivation to change they may lack the skills needed to affect change and be more easily derailed from their best intentions.
The bulimia nervosa individual may also experience greater feelings of shame and defectiveness. The bulimia itself may be an additional object of shame. The obvious signs of starvation among anorexia individuals to communicate feelings of distress are more recognizeable to others because of the loss of weight. The individual suffering from bulimia is more likely to keep their behaviours a secret and go unnoticed for longer because they are within a more normal body weight (Serpell & Treasure, 2002).
Another striking difference between the themes mentioned in comparing anorexia and bulimia is that BN individuals did not mention the ability to communicate emotions or distress, or positive consequences such as improved fitness levels and amenorrhea. These differences highlight the possibility of a different symptomatology of the condition in that deliberate starvation may be less common in bulimia than in anorexia. In terms of the language they use individuals struggling with anorexia use language related to food thoughts more whereas individuals dealing with Bulimia show a bias towards weight and shape related words (Serpell & Treasure, 2002). However, some clients may be more
128
sensitive to acknowledging expressions of shame and guilt related to the behaviours, and other clients may wish to appear compliant (Serpell & Treasure).
Serpell et al., (2003) in another research study related to pros and cons with children and adolescents suggested that internal reinforcers play a more powerful role than social reinforcers (such as attention and praise) in the maintenance of the disorder. Focusing on perceived positive aspects such as their own sense of control could prove more beneficial.
Serpell et al., also found significant differences between child, adolescent and adult in their scale of pros and cons. Younger adolescents tended to have less agreement of feelings of specialness, stifled emotions or feeling trapped. Younger individuals may be less aware of the long term implications of the condition, or may not have the cognitive development to understand the implications of the long-term consequences.
Understanding how the individual feels about the pros and cons of the disorder provides information on the level of cognitive development which will affect the way that the therapist needs to disseminate information or conduct interactive therapeutic sessions.
The therapist needs to work to help individuals accentuate the negatives and eliminate the positives (or vice versa), or alternatively help them to view other less harmful ways that these positives/negatives might be considered.
Knowing the pros and cons of the eating disorder also has implications for understanding ego strength, and how clients view individuation, personal boundaries and power and control issues. Understanding the differences in how younger people view the various eating disorders may have implications for how the disorder is formed. Knowing more about what might be preventing change means that the therapist can match therapy interventions to individual needs (Serpell et al., 2003).
129
Sometimes with eating disorders there is a tendency to believe that they stem from the same thinking patterns. These pro and con studies are helpful in showing the differences that exist in how individuals suffering from anorexia and bulimia think. Discussing beliefs and values is a critically important part of honouring the spiritual dimension of the individual’s life by helping them compare and contrast their beliefs and values with others in this group process. This section is particularly relevant for understanding the ego stroking nature of this disorder and the detrimental affects of holding certain stubborn beliefs and values to help motivate these individuals to change.
130
CHAPTER VI
Literature Review – Eating Disorders
Recurring Themes with Eating Disorders
This chapter identifies and discusses recurring themes that crop up time and again in the literature such as perfectionism, hopelessness and helplessness, control and ambivalence which often appear to be at the heart of these disorders. They were considered fundamentally important issues to address in the development of this spiritually based group program. The chapter concludes with a discussion of the trajectory of the disease and the considerations on what may impact future prevention, harm reduction, treatment and after care services.
Perfectionism
According to Manley and Leichner (2003) a number of recurring themes related to anguish and despair are popular in the eating disorder population. Many adolescents express feeling undeserving of help in general and not deserving of other people’s love, support or time. Manley and Leichner also suggested that they may overvalue emotional control and independence and, therefore, feel a need to recover on their own. Given that these are often individuals who are perfectionistic high achievers who display a marked need for control, asking for help may be seen as a sign of weakness that contributes to a sense of failure and shame. These teenagers accept that it is okay for others to have needs
– but not them.
Eating disordered individuals rarely encounter the joy of success because they are unable to meet their own unrealistic demands and expectations. They set themselves unattainable high standards with the result that a sense of poor self-esteem and a low
131
sense of self-worth becomes a self-fulfilling prophecy (Kirkpatrick & Caldwell, 2001).
Although these adolescents may be good students or athletes they are often blind to their own strengths and abilities. Their fear of failure becomes a debilitating reality even although there may be evidence to the contrary (Pipher, 1994; Manley & Leichner, 2003).
Hopelessness and Helplessness
A feeling of helplessness and hopelessness in being able to cope with the eating disorder itself is often pervasive (Manley & Leichner, 2003). Given that individuals are often physically and psychologically exhausted they sometimes feel that they are losing the fight. Charpentier (2000) suggested that individuals fear that the eating disorder will punish them even further for taking steps to improve their health. Research also suggested that adolescents are often ill-equipped to identify, let alone express their own affective states, perhaps because they do not recognize them (Manley & Leichner).
Individuals with an eating disorder often have difficulty articulating their concerns, are uncomfortable expressing their feelings, or find them a source of embarrassment (Manley
& Leichner; Lelwica, 1999; Pipher, 1994).
A Sense of Control
Many adolescents describe the eating disorder as giving them a sense of control over the more negative things in their lives. These teenagers often develop a sense of specialness where they are now the individual within the family who is receiving a lot of attention. Eating disordered individuals also believe that if they are thin they will be more attractive and likeable (Serpell et al, 2004). Manley and Leichner (2003) suggested that self-harming thoughts and behaviours including self-mutilation, suicide ideation gestures and suicide attempts become coping mechanism in a greater need for control.
132
Ambivalence
Many individuals in this population while seeming motivated are often ambivalent regarding getting better or vacillate between seeing the eating disorder as either a friend or an enemy. Most of them talk about being torn between two masters, one wanting to get better, and the other wanting to stay with the status quo (Charpentier, 2000; Manley &
Leichner, 2003; Serpell et al, 1999). Individuals with an eating disorder can become deeply suspicious of family members and caregivers because they think that they are either trying to fatten them up or that they will coerce them into giving up something that they feel is keeping them alive and in control. These adolescents also often think that individuals who offer support will be unable to help anyway (Manley & Leichner).
This section is important in understanding how some adolescents may overvalue physical and emotional control and how perfectionism and the fear of failure may leave them unwilling or unable to acknowledge their own strengths and abilities. Critically important is understanding the powerful role that ambivalence plays in wanting to improve their health and the pervasive sense of hopelessness and helplessness that leaves them feeling physically and emotionally exhausted for much of the time.
Issues for Future Consideration
A better understanding of the spectrum and presentation of the disorder will help promote the creation of more appropriate developmental management guidelines to provide improved outcomes for children and adolescent with these disorders. As suggested by Robin, Gilroy and Dennis (1998) further study is needed to describe the natural history and chronic complications of early-onset eating disorders to understand more fully the psychological, emotional, physical, social and spiritual consequences.
133
The issue needs further consideration of early identification of children who may be at risk, early intervention programs, and better services across the spectrum of disordered eating including services for the morbidly obese. Further clarification also needs to be established on the impact of starvation, binge eating and purging in children and adolescents. Identifying the differences between poor coping skills and symptomatology of the disorder, and whether an individual is in a precontemplation phase rather than suffering from poor judgement or lack of motivation also needs further study.
Given that evidence suggests that both eating disorders and co-morbid factors may be on the increase (Pipher, 1994) consideration needs to be given to the increased numbers, chronicity and the possibility of increases in both male and female children with a parental link. The future may hold increased collaboration between services across age groups, increased partnerships between public and private sectors, and between partnerships for care. Or alternatively, this increase may mean increased tension between public and private sectors, a proliferation of private services of questionable quality, or a breakdown of resources offered due to lack of funding. These are important considerations for all counsellors to reflect on who deal with this population. It is important to ponder potential pitfalls and future scenarios so that all health care professionals can consider individually and collectively some planning for the future.
Also how one can make a difference, and to consider ways that stronger links can be forged between agencies.
134
CHAPTER VII
Literature Review – Art Therapy
This chapter discusses art therapy as a more holistic and spiritual process. It includes a historical overview from its inception, debates the benefits of product versus process, considers the evolution of art therapy, and chronicles how it is practiced today. The chapter also explores why art therapy is important, the goals of the art therapy process, and the tools of the trade. It concludes with consideration of the benefits of using art therapy with eating disorders, the limitation of the experiential approach, and observations on the lack of empirical data on the use of the art therapy process for therapeutic intervention and assessment. This information is important in educating the reader about the value of using an art therapy approach, discussing the relative benefits and limitations inherent in the experiential process, and understanding the importance of participating in the creative process.
Art Therapy
Art therapy is generally thought of as a holistic approach to intervention because it highlights a spiritual and cultural dimension of an individual towards healing using symbolism in the struggle for transcendence (Betensky, 2001; Case & Dalley, 1992;
Dosamantes, 1992; Knill, 1995, 2001). Art therapy is associated more with doing rather than thinking. McCormick (1996) suggested that it may bridge the gap between different worldviews more effectively than a dialogic process because it incorporates the spiritual component of individuals’ lives in a more holistic way.
The practice of art therapy also attunes more to things temporal, having the mind and body at peace, looking for an order or organic in each task, and finding harmony or
135
dissonance by allowing the art to speak (Koepfer, 2000; Levine, 1995; Lewis, 1993). Art therapy gravitates more to an Aboriginal or Eastern belief of the universe in balance, being interconnected, living in harmony with nature and the environment. The philosophical concept embraces the idea of working holistically, balancing all things, with cyclical transcendental forces at work (Blue & Darou, 2002: McCormick, 1996).
Art therapy is considered an effective therapeutic method for exploring the here-and- now, the past, the unconscious, the meaning of life and freedom and the ultimate concerns of social responsibility and decision-making (Johnson, 1991, 1998). The art therapy process can be used effectively with many different populations and many different cultural, age or gender groups (Case & Dalley, 1992). Art therapy is also a viable option for therapeutic intervention at a time when strong family support units may be disappearing, and economically driven health care systems threaten the existence of extensive and thoughtful psychotherapy (Litt, 1995).
Although it is not generally thought of as a conceptual theory of psychotherapy art therapy is used as an adjunct with many theoretical frameworks in a wide variety of settings from education to rehabilitation. As a therapeutic option, art therapy continues to gather momentum because the process appears to work effectively with most traditional therapies. Since art is multidimensional, art therapy is always thought of as a here and now experience that evokes not only an image but feelings and emotions. The process elicits a distinctly psychological happening in the imagination through an emotional kind of felt sense (Johnson, 1991, 1998).
Understanding culturally appropriate, humanistic and spiritual healing practices of
East and West can mean practicing more competently, respectfully, fairly, caringly and
136
ethically with less fear of discrimination (Pinderhughes, 1989; Poonwassie & Charter,
2001). Learning to understand the difference of defining the self as having an ego that needs to be transcended as opposed to strengthened may have greater therapeutic possibilities. The art process also produces the curative factors that Yalom (1995, 2002) talked about regarding group process because it mobilizes beneficial resources and possibilities to facilitate development and solve problems of living.
Using the developmental theory espoused by Erikson (1968) that adolescents’ psychosocial stages of development and psychological needs are developing in tandem with conceptual, linguistic and metaphorical abilities, art therapy may be particularly suitable for individuals suffering an eating disorders. Moon (1998) argued that art therapy may be the language of choice for many adolescents because adolescents begin to move beyond the mimicry of childhood and start to develop an actual understanding of words, concepts, double entendre, exaggeration, parody and caricature.
Particularly, I am attracted to the way that the art process often utilizes silence, which speaks directly to me of humility (the counterbalance to the overzealous expression of truth), especially when the needlessly assertive point of view is mine. Otto
(1957) suggested that silence has a threefold character – there is the solemn observance of silence that becomes Sacramental, the silence of quiet time spent waiting, and the silence of Union or Fellowship (Otto, 1957, p. 211). Silences can culminate in a more powerful wordless experience because it may evoke “… a fellowship, communion and
“brotherhood of the spirit” pertaining to a special time and hour and needing particular preparation …” (Otto, p. 212).
137
The analogies that Otto (1957) used to express the experience of the transcendent in gracious intimate presence as a poised anticipation of the “……preparation of the soul to become the pencil of the unearthly writer, the bent bow of the heavenly archer, or the tuned lyre of the divine musician.” (p. 211), speaks to me. Using the silences has often helped me to maintain the balance between helping and enabling. The spiritual process evoked through art therapy should be considered something precious and rare that is drawn together from every day experiences that becomes the most intimate privilege.
Art Therapy Historical Overview
In the 1930’s and 1940’s, psychoanalysis as a therapeutic modality was in its zenith and dominated as a theoretical perspective in both Britain and the United States. When
Margaret Naumburg and Edith Kramer were coming to prominence in North America with their writings about art therapy in the 1950’s, psychoanalysis was primarily being used in the more traditional psychiatric settings of hospitals and schools for the emotionally disturbed (Allen, 1992, 2001).
Symptoms were said to arise from conflict in the patient’s past and treatment focused on the therapist as a kind of narrator of the individual and their story using language or symbolism as a kind of rhetorical tool. Psychoanalysis was based on a medical model that assumed symptoms had an internal dysfunction and historical etiology with syndromes leading to emotional distress that had biological origins (Corsini & Wedding, 2000).
Solutions for psychological problems often meant that the primary focus of practitioners of art therapy was as a clinician (Allen, 1992, 2001).
The therapist assumed the role of a model of transference instrument, analyzed the immediate presenting material in terms of conflict, elucidated this information related to
138
unconscious childhood fantasy, and then interpreted how this impacted the patient’s current functioning (Arlow, 2000). The Freudian notion as one of corrective and comprehensive interpretation of a patient’s symptoms through the symbolism of dreams, fantasies and free association influenced two schools of practice. Margaret Naumburg
(1987, 2001) emphasized free association based on the belief that unconscious processes have an upward drive that seeks consciousness. Edith Kramer (Kramer, 2001a, 2001b,
2002) emphasized the defense mechanism of sublimation.
Art therapy was also influenced by the European lens through which psychology was viewed and the zeitgeist on the theory of mind and reality espoused by writers and scholars prevalent at that time. The various art movements of the day such as
Impressionism, Surrealism, Art Nouveau and Art Brut explored the unconscious processes and personal, political and religious themes considered taboo (Nead, 1990).
Artists were breaking artistic conventions related to art, beauty, the male gaze, and the visual portrayal of humans related to Gods and religion (Nead, 1990). Artists were also tackling political and social discourses surrounding imperialist domination, racial and religious tensions both within and between cultures, and male and female relationships
(Nead, 1990). The art process as therapy was based on psychoanalytic theory with an emphasis on the unconscious and symbol formation as visual language.
Art Product Versus Art Process
Edith Kramer and Margaret Naumburg two leading pioneers of art therapy in North
America believed that art and art therapy complemented each other. Both were unequivocal in their view of the need to continue to practice their own art in their own lives on an on-going basis. Both women always made time for their own art-making as
139
essential to their own growth, and critical to understanding the artmaker’s intention
(Naumburg, 1987, 2001; Kramer, 2001a, 2001b, 2002). Both practiced a form of meta- analysis by gaining insight from firsthand experience, testing these insights in their work with others, and then re-engaging through reflection with their own processes a second time.
Kramer and Naumburg believed the distinction of the art therapist from other kinds of health professionals was in understanding and responding to the artwork in its manifest and latent content (Kramer, 2001a, 2001b; Wadeson, 1980; Wadeson, Agell, Minar &
Bush, 1994). The strength of the art therapist was in helping the client believe in the non- verbal and symbolic process by utilizing the media, searching for ideas and developing the individual’s own strengths. However they both used the psychoanalytic concepts in different ways. Kramer put the emphasis on art where completion of the creative process was the central goal, and Naumburg placed the emphasis on the therapeutic process
(Ulman, 2001).
Naumburg was influenced by a repressed, Victorian upbringing which may have been one of the reasons she came to regard creativity as one of the basic and primary urges of human endeavour (Ulman, 2001). Her educational training gave her the impetus to fight for more open, less restrictive educational approaches focusing on the individual child’s emotional needs. Naumburg’s training as a psychologist fed her belief in an analytically oriented approach to art therapy where the conscious and unconscious, and transference and countertransference relationships between client and therapist were central to success.
140
Naumburg believed that images produced through free association were powerful symbolic speech that served as a form of communication which gave direct expression to dreams, fantasies and inner experiences in symbolic form, and established a permanent record of something expressed at a specific moment in time (Ulman, 2001). In regard to using the art as a dialogue between client and therapist, Naumburg felt that the resolution of transference was made easier because the art came to substitute for a previous dependence on the therapist.
Edith Kramer was influenced by many of the symbolic and surrealist painters of the day and she felt it was important to attempt to define the definitions of art therapy as a profession and to continue to emphasize the special contribution art therapists made to psychotherapy. Kramer emphasized art and chose to focus on the product of art-making.
Particularly, she focused on sublimation where images created contained and symbolized emotions of primitive urges that were transformed through conscious and unconscious acts (Ulman, 2001). The value of defense mechanisms such as displacement, projection and sublimation were important as a way to protect or support the ego while cultivating the development of identity (Warson & Zajac, 1999). Sublimation suggested that by projecting interior images into externalized designs the individual could release repressed, unconscious material into consciousness.
Kramer also felt that the magic of art therapy as a psychotherapeutic modality was providing individuals with creative experiences that could be “…chosen, varied, repeated at will…” so that conflict could be “… re-experienced, resolved and reintegrated …”
(Ulman, 2001, p. 17). Using the premise from psychoanalytic theory that instinctual drives through the three major subdivisions (Id, Ego and Superego) are constantly vying
141
for superiority, the art-making through sublimation, integration and synthesis offered a wider range of human experiences by creating equivalencies for those experiences
(Arlow, 2000; Ulman, 2001).
Although Kramer emphasized the product of art therapy more than the process of art therapy, the primary goal was to support the ego. Kramer would not consider this approach to be a substitute for psychotherapy in the more conventional sense (Ulman,
2001). She believed that psychiatric procedures where artistic values were of secondary importance, was not art therapy and emphasized physical labour (doing as opposed to thinking about doing) as an inescapable part of the creative process (Kramer, n.d.; as cited in Ulman, 2001).
In comparing these two approaches one can see how they concentrated on different concepts within psychoanalytic theory. However, they both believed in the power of these processes as a communication tool, a form of catharsis by acting as a temporary repository for pent-up anger or anxiety, and for the potential to function as curative factors (Kramer, 2001a, 2001b, 2002; Naumburg, 1987, 2001). The nature of a current set of problems related to family background, childhood development and revelations of thoughts, behaviours and feelings was articulated through the art therapy process. Kramer and Naumburg both endorsed the role of the psychoanalytic art therapist to be a neutral observer that encouraged the re-expression and interpretation of the unconscious experience free of direction, threat or coercion (Ulman, 2001).
Art Therapy - Evolution
Although Freudian psychoanalysis was one of the great innovations of the end of the
19th century and start of the 20th century, and was the mainstay of mental health therapies
142
only fifty years ago, by the 1940’s and 1950’s cracks were beginning to show in psychoanalytic theory (Osborn, 2001). In classic Oedipal fashion, competing theories began revising Freud’s theory or rejecting the master outright. The talking cure started its fall from Grace and beliefs about health and wellness were broadening. Attitudes to insanity were changing and the role and perception of art therapy in the context of post
WWII rehabilitation and treatment was being carried along on this new groundswell
(Corsini & Wedding, 2000: Nead, 1990).
Today, the psychoanalytic theoretical approach is criticized for being too abstract, not parsimonious or practical enough and suffers from baggage from the past in being seen as a protracted theory which is expensive and backward looking for the root cause of symptoms. Another criticism is that psychoanalysis may prevent individuals from either living in the present or planning for the future (Arlow, 2000; Douglas, 2000). Within a health care system where cost is a critical factor, this has implications and raises the question of how relevant a theory it is in a market that is economically driven, theoretically competitive and culturally diverse (Corsini & Wedding, 2000).
It may be something of an anachronism in that psychoanalytic intervention is no longer as relevant for a culturally diverse population. A theory that emphasizes the self, self-revelation and building ego strength is not the primary goal of therapy for many cultural groups who de-emphasize focus on the self, emphasize interconnectedness and circular causality, and the ability to transcend the ego as opposed to conquering it (Arthur
& Stewart, 2001; Esses & Gardner, 1996).
Some cultural groups view therapeutic methods that concentrate on the individual as self-indulgent, not flexible enough to cater to the needs and capabilities of the individual
143
as a unique being with cultural affiliations. The reliance on cause and effect, insight- oriented outcomes and hypotheses that rely on latent content are hard to assess, difficult to measure with any accuracy, and may be impossible to validate.
There is also the criticism of viewing individuals problems from a pathological and sickness model of personality rather than a growth model that focuses on prevention rather than cure (Agell, 1998; Arlow, 2000; Mosak, 2000). Psychoanalytic theory has a tendency to underestimate the role of social and political pressures in shaping personality
(Mosak, 2000). Watts (1996) suggested that conflict does not necessarily lead to aggression or malfunction, differences can be worked out amicably, and individuals are not always victims to their instinctual needs.
Art Therapy Today
In the 1950’s, Humanistic, Existential and Transtheoretical models of psychotherapy began springing up providing a new opportunity to view human nature, health and neuroses from many different angles. Art therapy branched out of the more traditional psychiatric settings for the mentally ill into the whole spectrum of the human condition and art therapists could now choose from a broader base of theoretical models on how to practice art therapy (Wadeson, et al, 1994).
Nowadays, many art therapists specialize in practicing through specific theoretical lenses such as Psychoanalytic, Jungian, Biological, Gestalt, Client-Centred, Experiential,
Bowenian, Structuralist, Strategic, Solution-focused, Narrative or Family Therapy
(Moon, 1998). Some practitioners prefer an integrative approach that is based on theories that seem to fit together. Others prefer a more eclectic approach combining a mix of some of the underpinnings of a number of the theoretical models without necessarily adhering
144
to a specific theory (Moon). Art therapy is now accepted as an adjunct to many theoretical frameworks and is recognized as having powerful preventive, therapeutic and rehabilitative opportunities for people of all ages from all cultures in a myriad of settings.
Given my own age and stage in life, I gravitate more to an Aboriginal or Eastern belief of the universe in balance, being interconnected, living in harmony with nature and the environment, and walking softly on the earth. I embrace the idea of working holistically, balancing all things, with cyclical transcendental forces at work. Art therapy may bridge the gap between different worldviews more effectively, allows me to work more ethically, and may be the natural choice of therapy for many adolescents.
Having been trained and worked with both cognitive/behavioural therapy and art therapy there is no question that both these disciplines are effective in different ways, and can be successfully combined. Intuitively, I also believe that the power of sitting in silence with a client while they work is sometimes a deeper, more powerful experience for the client and the therapist than the silences engendered in the dialogic processes.
Particularly with eating disordered individuals who are sensitive to any kind of circumlocution, sitting as silent witness often strips away guardedness more quickly.
The expressive therapies, have superior potential for engaging all of the senses and bringing forth the creative forces that lead to growth. While being aware of my own biases here, I have found that witnessing the experiential process of the client is more therapeutic for both client and therapist. The coup de grace may be the ability to unleash a spiritual and creative awakening that is analogous to the hidden and unseen processes that occur in nature (Naumburg, 1987).
145
Why is Art Therapy Important
Why do people draw, dance or play music? Are these a form of solitary play, social activity or social influence? Art therapists posit that the practice of creative arts can be an indication of emotional state. Awareness of the creative process is helpful for understanding the cognitive, motivational and emotional factors inherent in that process.
Inner states are projected into the arts media, transformed in health promoting ways and then reinternalized. Using the spirit of play during the process of creation, provides an opportunity to play, to look for an order or an organic in each task – to be in the moment
(Winnicott, 1971, 1971a).
As Rhyne (2001) suggested, art-making has a lot to do with the way one sees, feels, thinks and perceives. So, when an individual engages in an art activity, they are experiencing themselves and what they produce. “It comes, not from a depersonalized it but from a very personal you……” (Rhyne, 2001, p. 115). Art has something to say that is uniquely tied to an individual from which they can make meaning of their own experience. Truth expressed aesthetically is one way to plunder the depths of the soul and express personal reality.
Jung (1968) relied heavily on the process of projection whereby aspects of the self are expressed in artistic products and processes such as play. The concept of projection provides the basis for asserting the arts reveal personal material which is presumed to be required in psychotherapy. Projection has been viewed both as determining the content and form of the artistic expression, suggesting a causal process linking art and the psyche in an attributional process in which the artwork is imbued with personal meaning after it has been created (Johnson, 1998).
146
It is suggested that it is not the arts media that holds the transformational power but the therapist that holds the capacity to interpret these projections by expanding the therapeutic space which incorporates an aesthetic space between client and therapist
(Johnson, 1998). Therapeutic interventions can occur at the creation stage in painting, stories, songs, poems, dance or theatre or when confronted by the finished work. Healing may begin when participants recognize themselves in the art and extend when they confront the Other in transitional space (McNiff, 1991, 1998; Winnicott, 1971a, 1971b).
McNiff (1988,1991) strongly advocated for the autonomy of the image and suggested that the artwork, role plays, images or poems revealed through the creative process should be viewed as independent beings and that the dialogue with the Other frees the client from already established schemas. He argued that it is the otherness of the image that contains most of the power to heal rather than the association with the inner life of the maker. This process of illumination and identification protects the person from anxiety because becoming the Other is a way of unconsciously locating and controlling it. By offering support and guidance through the arts media the Other is revealed and the vulnerable, yet healthier Self may be retrieved.
Cassirer (1944; as cited in Stevens, 1998) suggested that humans are constantly engaged in a dialogue with their own unconscious psyches as well as with cultural symbols and that, within the phenomenon of human consciousness, they constantly reflect on their condition. This pillow talk with the ego is analogous to the projection or externalization of unwanted or unknown parts of the self onto play objects and behaviour that would seem to facilitate a psychotherapeutic change to occur. As conscious elements of language, myth and art that are part of the individual’s universe are bridged, it often
147
elicits a flash of insight – a “Eureka!” moment! Suddenly arising insights do not follow a conscious sequence of reasoning but exist on the plane of imagination (Stevens).
Cassirer (1944; as cited in Stevens, 1998) suggested that humans have so surrounded themselves with rites that it has become ingrained in their understanding of knowing which has a direct impact on the notion of transitional space that is aesthetic, imaginal and metaphoric in which inside and outside, self and other are mixed. Cassirer (1971a,
1971b; as cited in Stevens) also suggested that art therapy may be a way to engage in meaningful play that branches out into other areas of encounter.
Winnicott (1971a, 1971b) proposed that play involves skill building and the ability to deal with issues such as separation and individuation, dependence, independence and intimacy. This way of knowing may be both a habit and style of cognitive functioning that can lead to wisdom. Lewis (1993) and McNiff (1991) suggested that this expressive re-experiencing and symbolic enactment within the transitional space of playing may be characteristic of healing in general. The dramatization and symbolic acting out of inner feelings and changes that an individual experiences may provide, not only tangible form and clarification to private feelings, but also precipitate insight and emotional adjustment.
This projection and externalization of unwanted or unknown parts of the self onto play objects and behaviour would seem to facilitate a psychotherapeutic change to occur.
A strong argument could be made that this playful experimentation through the creative art processes may be an antidote to various maladies that afflict the human condition because it attunes to the pure commitment of being, or to a commitment to things other than ourselves. The art process seems to distinguish humans from other animals.
148
The Goals of Art Therapy
The goals of art therapy are to support the ego and foster the development of identity by promoting individuation, separation and maturation. Participating in art therapy can also encourage the expression and interpretation of unconscious experience or to be in the moment. The art therapy process allows creative self-expression and self-actualization by allowing the confrontation of both rational and irrational thoughts and beliefs, provides historical permanence, objectification, a special matrix and release of physical energy
(Moon, 1998; Wadeson, 1980, 2001).
Tools of the Trade
The techniques often used in art therapy include body awareness, focusing, cognitive restructuring, guided fantasy and imagery, enactment, and mental experiments using the art process for making meaning (Moon, 1998). The therapist examines, not only what is being said but how comfortable, confident and competent the individual is or how they function in tasks that require some level of competency. Paying attention to the media chosen can fill in pieces of the puzzle in understanding individuals - not in isolation but in conjunction with other focal areas (Moon). The therapist also looks to generate an informed but objective emotional response to the artwork by staying in tune with the disciplines of looking, listening, and being with the individual (and the artwork) while monitoring their own internal reaction on different levels (Moon).
Do individuals require structure and value their work (or not)? Do they invest creative energy, perform mechanically or find pleasure in the work? Do they interact well with others? What are the silences saying? Do they become anxious at the sight of a blank white page? Is their response mechanical and without narcissistic pleasure? Is the end
149
product an expression of them? Do they ask for help and want someone else to structure their activity? Do they make reference to themselves or their body image and in what way? Paying attention to these kinds of questions provides a wealth of understanding
(Moon, 1998). Whether individuals are open to the process, invested in learning new skills, or rely on more familiar processes may give insight on how to move forward.
The therapist also has to consider the overall feeling tone of a given image and what it evokes within themselves which is based on their ability to be open to the image and not project values of worth or interpretation onto the artwork. By staying in tune with the disciplines of looking, listening and being with the individual and the artwork while generating a more objective emotional response, they can monitor their own internal reactions on these different levels (Moon, 1998). The art process and the choice of media may cast light on the individual’s worldview or frame of reference through the client’s choice of task, style of implementation, interactive style and image content (Moon).
Choice of media, tools, physical motions, postures, verbalizations and the lines, shape, texture and colour, as well as the created image itself, may represent unconscious needs, drives, perceptions and feelings.
The ability to project, transform and reinternalize the whole process and the ability to look back retrospectively on what has been done provides historical permanence.
Sometimes insights do not necessarily happen until long after the artwork has been produced. Another benefit of this process is that you can look at several different problems simultaneously such as issues with parents, friends, relationships and self
(Moon, 1998).
150
Art therapy as an experiential process may indirectly be responsible for insight in a different sphere of an individual’s life that may never be articulated or understood in the art directly. Therapeutic value is generated just playing with the art and there is often a deep and profound connection in the therapist bearing witness to that process. In the therapeutic interaction between the client and therapist, client and art, therapist and art, potential for therapeutic happenings between all three is possible (Kramer, 2001a, 2001b,
2002; Naumburg, 1987, 2001).
Creative art therapists continue to debate whether this transformative process occurs naturally, is reliant on the therapist’s interventions, or results from unique aspects of the artistic media. Art therapists also differ on the importance of the therapeutic value of verbalization in this integrative process. However, practitioners all seem to agree that using an art form as a natural primary process is a vital and valid method of externalizing and concretizing an individual’s imagery in helping to uncover and explore repressed material between verbal communication and non-verbal expression (Betensky, 2001;
Case & Dalley, 1992; Dosamantes, 1992; Landy, 1998; McNiff, 1989, 1991, 1998;
Robbins & Sibley, 1976).
The Use of Art Therapy with Eating Disorders
Given the developmental needs of adolescents there are many reasons why art therapy and adolescents complement each other. Linesch (1988) has documented the important relationship between adolescents’ emotional health and self-expression. Moon
(1998) suggested that art therapy is the therapy of choice for many adolescents because their cognitive, linguistic and symbolic languages are developing in tandem. They also
151
live in a world of visual images which is why they are so heavily influenced by pop culture (Kahn, 1999; Wadeson, 1980).
Art therapy is usually less threatening for adolescents because it is less hierarchical and art therapists are less likely to present as an authority figure (Riley, 1988, 1994). My experience has been that many adolescents gravitate more to the art therapy process because they find it less intimidating for exploring the eating disorder than many of the more traditional dialogic therapies (Williams, 1976). Individuals suffering from an eating disorder seem to consciously or unconsciously set themselves up to resist the dialogic process, whereas they seem less willing or able to maintain these same barriers in the experiential process.
The art therapy process is particularly helpful for exploring physical and psychological boundaries and experiencing issues around their own identity (McNiff,
1998). Art therapy is often more appropriate for adolescents with other more varied developmental, learning, social and emotional needs (Acharya, Wood & Robinson,
1995). Facilitating free expression and creativity can be a tremendously liberating experience and it can help with body image disturbances, depression and obsessive compulsive features. Encouraging some individuals to be more untidy, less rigid and more spontaneous, while motivating other individuals to be more controlled and orderly, has superior potential within the art therapy process. Working through visual perceived and idealized body image can help to acknowledge discrepancies and work towards greater change and growth.
Sometimes adolescents find it difficult or impossible to articulate their concerns dialogically but find the art process an easier way to begin a dialogue (Rhyne, 2001). At
152
other times, I suspect their initial engagement in art therapy is a way to substitute for the therapeutic work of more cognitive therapies. These young people see it as more enjoyable even although it can engage them on a deeper level and be more disturbing for them at times. Eating disordered individuals seem much less defended and if they are suspicious or reserved in the early stages it usually dissipates more quickly. In the early sessions participants usually need to be directed, will rarely come up with spontaneous art, and the artwork usually looks sad and impoverished.
Participants’ demeanour and behaviour in the early art therapy sessions is usually controlled and guarded but individuals normally relax when they begin to understand that their work is not going to be graded or criticized. As rapport and trust builds participants show more confidence with tools and media. Once individuals become comfortable with the process, know where to find things, and can make more of their own choices the artwork often blossoms into quite powerful and insightful pieces through experimentation with colour, shape, form and design.
A major distinction that I have found between individuals who are suffering from anorexia nervosa, and bulimia nervosa, is in their approach to the various media.
Anorexia clients are usually more perfectionistic, like to be more controlled and tentative in their approach to the art tools, media and subject matter. These individuals have great difficulty initially in being spontaneous, creating untidy art pieces, and being messy is anxiety provoking for them. Conversely, bulimia clients appear more relaxed and more talkative yet they have difficulty in knowing when and where to stop in their art process.
Generally, they can articulate themselves well but the appearance of being talkative and easy going hides a mountain of insecurities. Eating disordered individuals have difficulty
153
acknowledging that they may have created anything worthwhile but they blossom and shine with genuine praise and encouragement as time goes on.
Limitations of the Experiential Process
No discussion would be complete without some consideration to the limitations that may be inherent in the experiential process. Art therapy is not for everyone and one just has to consider the lives of the painter Vincent Van Gogh or the dancer Vaslav Najinsky to realize the failure of art creativity to always be therapeutic. Corsini and Wedding
(2000) suggested that there are many diverse theoretical models to explain therapeutic action with no clear winner between the various models in terms of therapeutic benefit.
There are unique aspects to each approach and advantages and disadvantages to every theory.
Art therapy may support criticism that art therapies are reliant on projective and externalizing defenses similar to the acting out of the behavioural model. Behaviourists would argue with the belief that individuals are creating, initiating agents and instead suggest that people are controlled by genetic and environmental histories. Debate around whether identification of the self (distinguished from the environment as a purely psychological process) does include a mature alteration of the ego is still ongoing
(Corsini & Wedding, 2000; Johnston, 1998).
Also, externalization and reinternalization as processes have received relatively little scholarly scrutiny, and reading into an image or symbol an outcome according to a well defined theory may miss the expandable and effective reality of the psyche that Carl Jung found so important (Corsini & Wedding, 2000). Jung (1968) believed strongly in the reality of the psyche’s ability to motivate the individual to unlock the doors to their
154
unconscious and that the therapist could stimulate creativity in clients in order for growth, development and healing to take place. Some people might take exception to the whole
Jungian archetypal philosophy of symbol formation having an adaptive function rooted in biology. Critics could suggest that symbols have nothing to do with biology but are merely manifestations of the culture generating them which opens up a debate on the influence of nature versus nurture and the role of the unconscious (Stevens, 1998).
Criticism could also be leveled at the idea that the whole process has a gender bias in its reliance on a stereotypical feminine process (affect). Understanding how humans perceive a three dimensional object on a flat surface could be another area of contention.
Sigmund Freud would probably argue that one of the major weaknesses to the creative art therapies is how the therapist manages to guard against contaminating the response to the work from their own neurotic needs (Arlow, 2000).
Observations
As a practicing cognitive/behavioural therapist and as an art therapist, I am aware of how much discourse is still going on in relation to the converging paths of both art and therapy and how the practice of art therapy is expanding both. The literature discussed here highlights a current debate that revolves around whether art therapy serves an adjunctive role to be tacked onto other therapies, or should be considered as a stand alone modality. I believe like Woodman (1990) that the creation of the soul has complementary masculine and feminine energies in everyone that can be supported through this process.
In my view, the art therapy field has not quite come of age as a stand alone therapy based on legitimate research. The art therapy field has produced less scholarly works and research studies than other mainstream therapies. I found a number of art therapy articles
155
that wrote about the what or how of art therapy but few that I would consider legitimate and rigourous process and outcome evaluation research. In doing the research for this project, I found that documented case or group studies related to spirituality, critical thinking, or eating disorders using an art or experiential approach were few and far between or did not exist at all.
Many of the criticisms pointed out above are valid depending on the belief system that you have around human nature and how the world works. Art therapy is a more intuitive process and therefore unlikely or impossible to view from an empirical standpoint. McNiff (1991, 1998) in suggesting that professions are placing boundaries and creating obstacles to furthering an artistic ideology based on the fusion of art and life raises the need to continue to consider this in developing future avenues for therapeutic interventions and assessments.
In considering the debate between whether someone needs to be an artist to be able to be an effective art therapist, or whether this may be a handicap, I respect the fact that there are good art therapists out there who are not practicing artists. I believe that the power of the methodology is ultimately in the relationship between people. However, it seems inconceivable for me to practice in art therapy without participating in my own art.
Given that I have used an aesthetic response for so long in my own art production, practicing my own art (in whatever form it takes) seems critical to reaching out to support others. Locating my internal core of integrity through my art-making as Allen (2001) suggested as a form of spiritual practice is, for me, at the heart of the matter.
If I treat an individual’s pain without taking on some responsibility to make meaning or to critique my own culture through my art-making, then I am not honouring the
156
individual who comes to me for support. I believe I can only take a client as far as I am willing to go myself. Both the process and the product have legitimate roles to play in the practice of art therapy, both should be used in assessments, evaluations and interventions, and there may be times when the product may be more helpful than focusing on the process. I see art therapy as a legitimate and full partner in an integrated approach to therapeutic interventions.
I like to believe in the vision for art therapy that McNiff (1989, p. 97) suggested where the structures of the formative elements are enhanced through a transformative process in which a whole greater than the sum of its parts is created. This new primacy will be developed through the fusion of artist, art teacher and art therapist (Kramer,
2001a, 2001b, 2002; Naumburg, 1987). Art therapy is a good foundation upon which to build a sound personal theory and ethical practice.
This chapter was helpful in giving a historical overview of the origins of art therapy and how it has evolved over the last fifty years. The discussion was important in considering that this approach may be a natural choice for many adolescents who may have difficulty articulating their concerns in the dialogic process. It is also considered to be an intervention that fits well as an adjunct to other therapeutic modalities that appeals across cultures in a myriad of settings. It tunes into the psychosocial stages of development and the psychological needs of adolescents suffering from an eating disorder because it engages all of the senses, highlights the cultural and spiritual dimensions of the individual, and connects mind, body and spirit together.
This chapter was also helpful in understanding how meaningful play can be nurtured both as a habit and as a style of cognitive functioning that may lead to wisdom. Fleshing
157
out the limitations of the creative or experiential process was also relevant in exposing the concerns that other health care professionals may have with the experiential process.
Considering that art therapy may contain the characteristics of healing in general that can precipitate insight and emotional adjustment, and that it may have superior potential for exploring the unconscious, physical and psychological boundaries as a liberating force for exploring body image disturbances, depression and obsessive compulsive disorders in a less threatening manner, may make it a better option for this program with this population.
158
CHAPTER VIII
Literature Review – Creativity
This chapter discusses the origins of the creative process and various perspectives from which to view creativity such as social psychology, narrative storytelling, constructivist meaning-making, flow theory and as a process of self-actualization. It explores the special connection between art therapy and creativity plus the role of the unconscious, using the creative process as a transitional object, and for building tension and ego strength. It also investigates the therapeutic benefit of creative play and as a way of conquering the unknown. It considers the important role of the art therapist and concludes with observations on the therapeutic benefits of telling real or imaginary stories in various sensory ways. Understanding the role that creativity plays within the therapeutic space is fundamental to the success of this group program.
Origins of Creativity
Bender (1981) suggested that individual creativity has its origins in the creation of the world and the evolution of living things and everything we understand in the rhythmical movements and patterns of the cosmic universe and the chemical reactions that occur in the atoms or in the tiniest grain of sand. The creative process is governed by the same laws and patterns that exist in time and space (Bender). Creativity is manifest in the most primitive visual/motor experiences and forms in the early maturation of visual/motor perceptions. It is found in the rhythmical, spiral, vertical, circular and sometimes tangential and gravitational movements that contract and expand from a mobile centre
(Bender).
159
Mace and Ward (2002) argued that real life creative activity is influenced by such factors as commitment, motivation, skill and effort. Patrick (1937) found that the creative working processes of artists and non-artists related to effort could not be differentiated.
Dudek and Cote (1994) concluded that problem finding and problem solving is not unique to creative thinking and could not be differentiated between artist and non-artist.
Getzels and Csikszentmihalyi (1976) found that fine art students who engaged in an extended problem-formulation creative process maintaining a high level of interaction produced work that was evaluated as more creative. Mace and Ward (2002) however, argued that in these former studies the experimenters dictated the art-making task whereas self-initiated work involved the interaction of variables that have gone unrealized in much of contemporary research. The creative process includes an individual’s personal developing aesthetic (Kay, 1991) and themes directed by influential life experiences and existential concerns (Jones, Runco, Dorman & Freeland, 1997).
Mace and Ward also suggest that creativity occurs and evolves over time rather than being actualized at a single point in time.
Mace and Ward (2002) in studying artists in self-initiated creativity found that creativity developed in four distinct phases: (a) artwork conception; (b) idea development; (c) making the artwork; and (d) finishing the artwork and resolution.
During this process there are multiple feedback loops where an earlier developmental phase can be accessed as well as being able to create new ideas at any stage in the process. The artwork does not arise from a conceptual void, nor is it determined in advance. It rises out of a complex genesis of art-making that involves making, thinking and ongoing experience.
160
Over time, the artist builds an extensive knowledge base about art-making that includes “… explicit and implicit understanding of technique, skills, art genre, art theory, aesthetics, emotion, values, personal theories, personal interest and experience, previous work, and historical and contemporary knowledge.” (Mace & Ward, 2002, p. 182). An interesting finding is that art concepts or ideas often emerge in the process of making other artworks and art work ideas can germinate for some time before any explicit work.
The process is dynamic and non-linear. It is likely that this knowledge is also the source of motivational and emotional variables that contribute to the creative process (Dudek &
Cote, 1994).
From a Taoist perspective, the art process is analogous to the movement of Heaven’s energy via the human imagination, through the body and into the earthy substance of the page (Miller & Cook-Greuter, 2000). According to Otto (1957) this creative energy has
“…… intercourse with Man in attracting him to it, seizing upon him, possessing him, breathing upon him and permeating him……” (p. 201) so that one experiences a penetrating glow and illumination, fulfillment, transfiguration where one is quickened through by it. While there are many different philosophical underpinnings on the subject of creativity and varying definitions regarding its nature, source and purpose, it generally refers to thoughts, activities, or products that break new ground or yield a product such as an image that is novel, surprising or useful (Rogers, 1993; Ulman, 2001).
The numinous occupies a more central position in Taoism because it originates in contemplative speculation of the mystery of the universe and the secrets of the world
(Otto, 1950). Miller and Cook-Greuter (2000) suggested that numinosity is similar to the union of essence (jing – the essential components of the physical body); energy (chi – the
161
energy that flows through all bodies; and the spirit (shen – the mind of the Tao). It is argued here that using the creative process to integrate the arts into daily life is critical to having a deeper connection and understanding of oneself and one’s environment. The numinous feeling is experienced by individuals as life or being of a religious attitude that is evoked through the human soul or spirit (Walsh, 1990a, 1990b, 1993, 1999a, 1999b,
2000).
Ulman’s (2001) suggestion that psychological forces and mechanisms involved in artistic creativity are closely akin to the human personality. Power comes from within the personality and creativity can help bring order out of chaos when confronted with a bewildering array of impressions and sensations from the outside world (Ulman).
Existentialists such as Yalom (1995, 2002) would posit that the self grows in relation to others and that the elements of the therapeutic relationship can facilitate creativity and transformation.
Cassirer (1944; as cited in Knill, 1995) suggested that the process incorporates an expansion of identity due to the transformation and healing that stems from creativity.
How individuals adapt to that plays a large part in how they stay psychologically healthy.
Goldberg (1997) suggested that less creative people may be susceptible to neuroses or psychological dysfunction because their active curiosity and passion for self-discovery has been thwarted with the result that, when they come up against life’s vicissitudes, they are ill equipped to roll with resistance.
Natalie Rogers (1993) stated that the internal conditions needed are a willingness to remain open to experience. The therapist can create the necessary conditions for creativity to occur by providing psychological safety and psychological freedom when
162
clients are not in a position to provide it for themselves. She suggested that when feelings are channeled into artistic endeavours such as the visual arts, movement and sound, we are releasing creativity and transforming it. Going with the flow, staying open to experiencing new concepts and beliefs, and being comfortable with tolerating ambiguity are all challenges to be overcome. The therapist needs to continue to practice these in their own life before they can nurture them in the client (Rogers, 1993). A critical component is offering stimulating and challenging experiences for the client to connect or reconnect in the comfort and safety of the art therapy space (Levine, 1995).
Social Psychology
Within the arena of social psychology the notion of creativity is a construct of the social system itself. Constructivist theory articulates a process of experimenting with new meanings and different possibilities (White, 1995). The process brings clarity around experiential reality, new vistas for understanding and new possibilities for action.
A Narrative Perspective
From a narrative perspective the creative process provides the opportunity to restory lives or reconstruct issues that are holding individuals captive. Through the process of co- creation new stories can be authored in the post-modern vein where there is no fixed reality and where many perspectives on reality and human experience can co-exist
(White, 1995).
Constructivist Meaning-Making
Moreno (1987) was instrumental in influencing early constructivist theorists in how role playing individuals construe themselves in relationship to others and how that played out in real life. Moreno (n.d.; as cited in Apter, 2003) suggested that spontaneity and
163
creativity are “……the pillars of good health……” (p. 32). Spontaneity is a type of energy that operates in the here and now and is also a momentary freedom to make new choices and free oneself to find new solutions. Creativity is produced, not through contemplative planning, but through a more spontaneous, improvisational process that is unprecedented and unpremeditated. Self-discovery is achieved through action which in turns generates vitality and playfulness (Apter, 2003; Blatner, 1992; Kelly, 1991).
Flow Theory
The idea of flow theory as envisaged by Csikszentmihalyi (1996) and related to creativity is a concept that is different from Moreno’s idea. The idea behind flow theory refers to a state of being where individuals are so immersed in a particular activity that nothing else seems to matter. Individuals are not relying on what has already been created. Their involvement is such that they are unaware of their surroundings, engrossed in the undertaking at hand, and are having fun doing it. Csikszentmihalyi suggested that creativity emerges when individuals are engaged and love a particular activity. A flow- type of activity is self-chosen, which engenders immediate feedback from the possibility of clear goals (Csikszentmihalyi).
Creativity as a Process of Self-Actualization
Maslow (1970a, 1970b) in his model of fundamental needs suggested that humans are generally activated and satisfied in a hierarchical sequence where motivation is the primary incentive in every human action. He called this state of awareness the flow experience. As lower needs are satisfied (physiological satisfaction, safety, belongingness and esteem) the individual moves towards self-actualization (higher or growth needs). He
164
suggested that the individual moves toward self-actualization where there is increased acceptance of self, others, and nature.
Carl Rogers (1980) also discussed the self-actualizing tendencies where discovery of the self facilitates transformation and constructive creativity that cannot be forced but is allowed to emerge. The higher self-actualized person has increased spontaneity, superior perception of reality, a more democratic structure, and greatly increased creativeness
(Maslow, 1968). The self-actualized person is the one who more easily forgets or transcends the ego, who can be “… most problem-centred, most self-forgetful and most spontaneous in his activities.” (Maslow, p. 42). He also suggested that spiritual experience is the ultimate in self-actualization which is a style of life which fosters the creative self.
Art Therapy and Creativity: A Special Connection
The nature of creativity, creative process and creative development has special significance for art therapists because art therapy, as a profession, is based on the healing power of artistic expression, the dynamics of creation as well as the relational dynamics involved in being creative. Some of the frameworks for understanding creativity in art therapy include object relations theory, social psychology and psychodrama. For instance, the interpersonal aspects of relationship in fostering creativity are stressed from an object relations and therapeutic perspective as mimicking the original mother/infant matrix.
Creativity - The Role of the Unconscious
Jung’s (1911/1956) idea that the unconscious is the source of creativity and meaning and the transformation process that brings forth creative symbols that perpetuate new
165
expression is also significant. From a Jungian standpoint, the collective unconscious uses images, themes, sounds and movement expressed through the arts, drama, music and dance as providing the sacred containers for healing. The human consciousness is enlarged through the creative generation of symbols which often requires a response that leads to change. The art therapist questions the idea that art is generated in an isolated system but, even if it were to be true, through relationship and participative action, this isolation is respectfully challenged.
Creativity – The Transitional Object
According to Winnicott (1971a, 1971b) creativity is the capacity to relate to the external world, while primary creativity is the ability of the infant to create the mother which is a necessary condition if the infant is to successfully achieve healthy physical and psychological functioning. The therapist also performs an intermediate function that holds the transitional space which bridges subjective and objective reality (Winnicott).
The analogy is used to understand the interplay between therapist and client where a holding space is tolerated and endured by the therapist because the client has lost the creative capacity to find things and, in effect, has lost contact with significant objects/persons with respect to feelings and intentions. Winnicott (1971a, 1971b) suggested that generating deeper levels of creative play and fantasy through being in the moment can produce greater capacities for transitional relatedness and a more vital contact with reality because other memories are not intruding on current action and play.
Creativity - Tension and Building Ego Strength
Kohut (1984) suggested that creativity as expressed in creative and artistic work provides a way of expressing tension operating within mind and body. Through a
166
transmuting internalization tension is transformed into a self-regulatory mechanism
(transitional object) that includes introjection through recall or imaging. The object is taken in but not yet identified, eventually it is identified and then absorbed into the individual in a three-step process. Tension is relived in the process of building ego strength. Kohut does not use Winnicott’s notion of the importance of the holding environment but he described a dyadic and triadic togetherness that seems in keeping with both Winnicott’s (1971a, 1971b) and Bowlby’s (1988) ideas on attachment theory.
Playful Therapeutic Space
Experiential art and play offers the adolescent the opportunity to experience growth under more favourable conditions by allowing them to express emotional conflicts or new ideas in the safety of the therapeutic space through symbolic speech (Winnicott, 1971a,
1971b). Visually through dance or music, or articulating through drawing, painting or sculpting individuals can use the imagination to reshape reality in a positive way.
Creative images or mental pictures are often generated more easily, or come to the fore more quickly, when the individual is in a more relaxed state (Winnicott, 1971a,).
Conquering the Unknown
Moore (2004) suggested that creative work can take one to the edge of human possibility where the landscape is as dark as the night sky. “You may not know where you are going or what you are doing but you have faith and a spirit of adventure that allows you to feel at home in the darkness.” (p. 208). Neither the client nor the therapist can know where they are going but the art therapist can help transform suffering into images that heal and hold the sacred space as a living container to facilitate creativity, the dialogue of images, and be a witness to that process (Moore)
167
Mind-Body-Spirit Connection
Schilder (1942) spoke of the mechanisms of the central nervous system related to spatial images that everyone possesses. Rossi (2002) saw creativity as a way to illuminate the creative possibilities of the mind and body to heal itself and transform psychobiological arousal and stress into health promoting properties at both the individual and cellular levels. He suggested that novelty, numinosum and neurogenesis are activated by our numinous experiences of wonder, mystery, fascination, curiosity and creativity. In effect it facilitates neurogenesis, the growth of the brain, and healing via stem cell differentiation and maturation (Rossi). Levine (1994) suggested that the art space in expressive therapy takes on the formlessness of Winnicott’s (1971a) play and the soul-making properties as espoused by Hillman (1989).
Bender (1981) suggested that creativity is helpful to an individual experiencing and differentiating their world and, in individuals suffering from brain pathology, it helps to understand self as separate from the external world. She also suggested that creative art production such as mandalas that have been passed down from the Paleolithic era helps in aiding contemplation and moving the spirit forward along the path from the biological to the spiritual. Jung (1968) referred to the universality of such images as appealing to the collective unconscious because it promotes maturation and individuation as an exploration of identity.
In gestalt therapy, creativity fosters the idea behind individuals developing the biological ability to see in whole images the individual body structure as the most fixed and primordial concept that differentiates with development or maturation. Creativity may be accounted for by human evolution and individual development and can be seen in
168
the primitive and global patterns in individuals which call forth a variety of defense mechanisms such as fear or anxiety through obsessive compulsive motions (Bender,
1981; Schilder, 1942).
Role of the Art Therapist
The art therapist spends a lot of time, energy and study investigating what facilitates creativity in their clients and they have a role to play in identifying, catalyzing, eliciting and fostering creativity in a co-creative process. Through seeing, hearing or feeling what is not being directly expressed, by reframing an individual’s perceptions, or by offering up an alternative vision the psychological meaning of both the description and event can change. Art therapists are particularly interested in the creative images produced by a client because they give visible and tangible form to external and internal experiences.
From an aesthetic perspective, it is expected that interacting with media and materials will bring forth sensory data that can act to touch the soul, evoke the imagination, stir the emotions and agitate the thought processes (Knill, 1995). The responsibility of the therapist is to hold the sacred space to allow the unknown to appear.
The response is subjective versus projective, sensory versus intellectual where the client’s inner world is conveyed or projected through their own inner expression (Knill).
The expressive therapist is trained not to impose their own aesthetic or evaluation judgement on the process or product. The focus is on the aesthetic as produced in the here-and-now which tends to be more fluid and suggestive and is a process that encourages the client to engage in the process rather than mentor their production of the product. Knill (1995) suggested that the aesthetic response considered here is not the same as the more formal aesthetic of ideal platonic forms.
169
A number of philosophical underpinnings guide expressive therapy approaches related to crystallization theory, polyaesthetics, aesthetic awareness and response to beauty. Crystallization theory suggests that through clarity and precision of feeling and thought creativity is embedded in the notion of “……human tendency to integrate disparate elements ...” (Levine, 1995, p. 10). The role of the art therapist is to help the client move towards optimal conditions for emergent images to disclose their meaning through a poiesis indigenous to art. The idea behind this is that the inherent power of the spoken and written word helps to bring order and logic into the therapeutic space.
Polyaesthetics sheds light on creativity through the idea of sharpened sensory perception that is accepted as being generated by all of the arts to some extent. From this perspective it advocates that creativity is enhanced by engaging in an interdisciplinary approach that involves all of the sensory modalities through the visual arts, dance, music and language. An essential function is that it engages all of the senses and expressive therapists must be able to shift from one art form to another in order to provide form and shape for creative expression (Knill, Barba & Fuchs, 1995; Levine, 1995).
Observations
In this project problems are viewed as a result of suppression of the imagination from which symbols and meaning are believed to emerge. Clients are encouraged to connect with their own artistic process, open up their imagination to other potential realities and tell their real or imaginary stories through creative expression that may involve the spoken word, visual images, bodily gestures, dramatic enactment or musical rhythms.
Change occurs through the telling or retelling of these stories with the therapist witnessing and supporting the evolution of regenerating narrative from the imaginal and
170
creative realm (Knill, 1995). The notion that creativity may stave off neuroses when one is faced with life’s trials and tribulations deserves further scrutiny. If artistic creativity flows from the personality it is critical to have a good understanding of how creativity plays out in real life situations. Using creativity to provide that centrifugal retracing in one’s own life and discovering the conditions that can provide that for our clients is at the heart of sound practice from an art therapy perspective.
This chapter was helpful in providing a context for understanding the notions of creativity from both Eastern and Western perspectives. Touching on the various theoretical understandings of the creative process suggested many different ways to view creativity without being mutually exclusive. The discussion was also helpful in highlighting the special connection that exists philosophically and practically between art, art expression and the dynamics of creativity.
Particularly relevant to understand was how the art therapist acts to provide physical and psychological safety to explore a way of being in the world. Also the benefits of working in relationship and community as a way to foster connections with objects and others in the world. The notions that underlie attachment theory which is a central goal of this group program. Growth, transformation, healing, playfulness, imagination, meaning- making, sublimation, self-actualization, and identity formation are some of the concepts that have been linked to the act of creativity.
The discussion provided insight on how art therapy can provide insight on visual/motor development, visceral functions, perception, concepts, symbol formation and language. In effect, art therapy may amplify the creative process and reveal relational patterns and processes connected to reality that manifest in slow motion (Bender, 1981).
171
The art therapy process can reduce tendencies toward rigidity and concreteness that can help to overcome disorganizing constructs. Apparent in depictions of the human form and other creative productions, creativity can provide a window on an individual’s impulsivity, fantasy life, language, self-identity and body image (Bender, 1981; Moon,
1998; Schilder, 1942).
Another centrally important process to understand in this chapter was the health promoting properties of using art experiences such as mandalas that contain soul-making properties and which have been used over eons to move the spirit along a path towards healing. The more recent idea of bringing forth the creative forces that lead to growth at the individual and cellular level is also a central premise of this group process.
172
CHAPTER VIIII
Literature Review – Critical Thinking
This chapter provides a historical overview including a taxonomy, characteristics and a definition of the critical thinking person. It explores how academia defines critical thinking and where the education of the critical thinking person has traditionally taken place. The discussion also challenges the traditional view of critical thinking with a new concept and definition of a critical thinking being. The discussion explores the future education of the critical thinking being, how this should evolve, how to improve learning across disciplines in many different situations and developing a community of inquiry.
This information is important and relevant for developing the individual as a supra- cultural, critical being, for nurturing critical consciousness, and considering ways to move away from disseminating psychoeducational information for the mind as passive listeners, towards a learning while creating, participating, connecting approach (Barnett,
1997; Crème, 1999).
Ten years ago when I started on this academic journey, one of the questions I wanted to answer was: What separates a good counsellor from a great one? It has become clear to me that one of the essential components to becoming even a good counsellor is the ability to think critically in order to develop the skills of competent and reflective counseling practice. What has crystallized for me is the need to understand and develop Critical
Thinking (CT) and its uses on both a personal and professional level in my own life so that I can help nourish that in the lives of the individuals that look to me for support.
173
An Historical Overview
While the term critical thinking is ubiquitous, and a great deal of theoretical literature has been written on CT, evidence suggests that CT as a concept remains esoteric and elusive (Astleitner, 2002). Also apparent is a dearth of practical, educational guidance resources that elucidate CT and provide practical, hands-on, guidance approaches to teach or nurture critical thinking (Haas & Keeley, 1998).
As a result of the failure of programs in promoting critical thinking in the 1950’s, a qualitative research methodology known as The Delphi study was initiated in which forty-six experts in research were asked to define critical thinking in an interactive panel process (American Philosophical Association, APA, 1990). The group consisted of men and women from the United States and Canada that represented many different scholarly disciplines in the humanities, sciences, social sciences and education. These scholars unanimously endorsed CT as being fundamental to the success of many people and nominated critical thinking the most important skill in knowledge management and arguably the most important present day educational task (APA). Since then there has been great debate over whether traditional educational methods actually teach CT (APA;
Facione, 1990, 1998; Walkner & Finney, 1999).
Many research studies have identified metacognition (thinking about one’s own thinking) as an essential part of CT (Astleitner, 2002; Facione, 1998). A number of studies suggested a decline in CT expedited by increased reliance on the performance of abstract, intellectual and cognitive functions (Alexitch & Page, 1996; Bercuson, Bothwell
& Granatstein, 1984). Astleitner also suggested that CT has been ignored and is not integrated into other areas of instruction.
174
Critical Thinking - A Taxonomy
Although an integration of existing theoretical approaches in critical thinking is still missing, it is possible to describe what individuals have to know for being successful in
CT. Dick (1991) used a taxonomy of critical thinking that summarized the relevant research over the last fifty years:
Table 1
An empirical taxonomy of critical thinking (Dick, 1991, p. 84)
Identifying arguments
Themes, conclusions, reasons, organization
Analyzing arguments
Assumptions, vagueness, omissions
Consider external influences
Values, authority, emotional language
Scientific analytic reasoning
Causality, statistical reasoning, representation
Reasoning and logic
Analogy, deduction and induction
According to this taxonomy CT consisted of identifying and analyzing arguments, considering external influences on arguing, scientific and logical reasoning. This taxonomy is closely associated with research from cognitive psychology, philosophy and linguistics where inductive, deductive and causal reasoning are central premises
(Astleitner, 2000).
175
Many sources identified meta-cognition as the awareness to control what one is doing by being aware of thinking as one performs a specific task (Brookfield, 1997; Facione,
1990, 1998; Walkner & Finney, 1999). Astleitner (2002) and Halpern (1998) suggested that critical thinking was a mental activity going across domains that evaluated arguments or propositions and made judgements that guided the development of beliefs and action.
CT represented a higher order thinking skill that needed a large amount of cognitive resources based on purposeful, self-regulatory judgement resulting in interpretation, analysis and inferences. This mental activity interpreted using evidentiary, conceptual, methodological or contextual factors.
Critical Thinking - Characteristics
Wade (1995) identified eight characteristics of critical thinking (CT) which involves asking questions, defining a problem, examining evidence, analyzing assumptions and biases, avoiding emotional reasoning, avoiding oversimplification, considering other interpretations, and tolerating ambiguity. Strohm and Baukus (1995), in Strategies for
Fostering Critical Thinking Skills, saw ambiguity as a necessary and even a productive part of the process.
Elder and Paul (2001) in a treatise on thinking with concepts, argued for a constructivist heuristic approach to CT that requires command of language as insight into social conditioning. These researchers suggested that students be taught to understand how these personally and socially indoctrinated concepts confine their thinking and prevent them thinking outside the box. Cheung, Rudowicz, Kwan and Yue (2002) analysed the validity of a measure of CT as a concept across situations. The validity measure showed that cognitive, motivational, ideological and behavioural dimensions
176
coalesced to identify a general concept of CT. Cheung, Rudowicz, Kwan and Yue argued that instruments created in the West required modification and adaptation where cultures
(including values and lifestyles) were different, and where English was not the primary language.
Critical Thinking - How Does Academia Define it?
Haas and Keeley (1998) argued that while the concept of CT had become very common in educational literature, evidence suggested that many faculty have not embraced CT as an essential value. These researchers offered evidence that professors asked few questions and that most questions were at the lowest level of cognition
(information): the most common pattern was lecturing, followed by low-level questioning, followed by more lecture. Fewer than 0.5 percent of questions could be classified as requiring evaluation (an important aspect of critical thinking).
Haas and Keeley (1998) also suggested that educators may not have experienced a critical thinking approach in their own education because their own models may have been dispensers of information. Faculty may see themselves as serious, effective, critical thinkers but the reality may be that they have never been trained in critical thinking (Haas
& Keeley). University educators have been validated as critical thinkers because of their advanced degrees, which may not necessarily be the definitive criteria. Haas and Keeley also highlighted the unrealistic expectation that critical thinking occurs as a process akin to osmosis.
These arguments suggested disparity between what some theorists conceived critical thinking to be and what was practiced by teachers. Astleitner (2002) argued that theorists have focused on developing critical thinking abilities, while many teachers concentrated
177
on content acquisition. He proposed that Faculty may not even understand the concept as constructed over the years by those convinced of its importance. Teachers were too busy teaching to a curriculum that required them to teach specific subject matter to worry about teaching students critical thinking skills and that textbooks and lectures tended to emphasize memory of facts, and exams were often geared to measure information retention (Astleitner).
Where has the Education of the CT Person Traditionally Taken Place?
Walkner and Finney (1999) identified the development of self-awareness through reflection as most useful to individuals and examined awareness using reflection in detail at preliminary, transitory and meta-cognitive levels, not just for students’ careers in higher education, but for use in autonomous lifelong learning. Hammond and Collins
(1991) suggested that most learners neither value nor practice active, critical reflection because they are too busy to stop and think and many educators do not reflect either because they are too busy teaching!
Bercuson, Bothwell and Granatstein (1984) in The Great Brain Robbery, provided evidence from the last ten years that suggested a decline in basic academic skills expedited by increased reliance on the performance of abstract, intellectual and cognitive functions using calculators and computer software. These researchers criticized testing procedures in academic courses including inflating grades and less rigourous academic, examination and admission standards. Braxton and Nordvall (1985) questioned the ability and competence of university graduates to think critically and criticized the move away from the goals of a liberal arts education to an education system based on self-centred, individualistic goals of financial and material success.
178
Alexitch and Page (1996) expanded on the problems previously mentioned and suggested that job preparation was now commonly seen as the most important aspect of university attendance, eschewing traditional academic values. Many elementary and secondary school educators and counsellors now emphasized job skills as the purpose, or guiding value, of higher education toward the selection of degrees and courses (Page &
Remigio, 1991). Paradoxically, there was also evidence to suggest that a strictly vocational approach limited students’ employment possibilities because of the reduced ability to problem-solve, adapt and cope with new technological changes (Alexitch &
Page).
Alexitch and Page (1996) also highlighted the distinction between intrinsically motivated students (based on personal growth, process, or learning intellectual competency) and extrinsically motivated students (based on grades, status, competition and recognition). Learning-oriented types showed interest in the philosophy/meaning of life and social justice, whereas the grade-oriented type emphasized education essentially predicated upon the preparation of a career (Alexitch & Page).
Alexitch and Page (1996) presented evidence that learning-oriented individuals generally became more intellectually competent adults and more likely to develop intellectual and critical thinking skills. Perkins (1986) highlighted the current dilemmas and the implications of feeding into the fears and anxieties of dumbing down the university experience as successive generations perform fewer and fewer complicated cognitive functions for a marketplace that requires less complex, less cognitive, less satisfying jobs. Siegal (1988) found faculty resistance to teaching CT.
179
In Search of the Critical Being
Barnett (1997) argued for the replacement of critical thinking by a holistic concept of critical being using critical imagination. This concept displaced the notion of CT as a set of skills separate from the person within a confined framework or tailored to fit the demands of a market economy, with the idea of a critical person that encompassed academic knowledge, the self and the world of action (Creme, 1999). Barnett suggested that in a post-modern world critical being needs to be conceived as a rigorous and collective process of becoming in which individuals become, not self-contained or transcendental, but social actors with a self referential capacity motivated from a sense of personal authenticity. He also argued for a critical life as being the major purpose and goal of higher education that should encompass critical reason, critical self-reflection and critical action manifested in a critical spirit.
Skelton (1997) in a critique argued that Barnett (1997) over-identified with a particular set of sociological and philosophical interests related to critical theory. He also suggested that there is little mention of traditional critical concerns, and little reference to gender, race, social class, sexual orientation and disability. Skelton also criticized the book because there was little of Barnett himself and his own development in it and because the text was unnecessarily complex and jargonistic.
Huges (1997) criticized Barnett’s (1997) idea of us and them ways of knowing and the disintegration of the current idea of self. She argued that in seeking to persuade against current values, he imbued the present with the terrors of excessive narcissism.
Huges also argued that the book was weak on considering how his knowledge had been
180
produced, without methodological note, and no account of how sources were identified, selected or dismissed.
Tapper (1997) argued that Barnett’s (1997) book was not a serious scholarly contribution to the social sciences but instead a contribution towards the philosophy of education built around a personal view of what should be the nature of higher education and its pedagogical shape. Tapper argued that a major flaw in Barnett’s conception was that it was based on an emerging historical context rather than embedded in a past sociological, political and historical context. Barnett’s (1997) book should have included more detail about the emerging world, why higher education as presently constructed was failing, and what the Barnett agenda would give students that they failed to receive now; including a benchmark against which to measure CT performance (Tapper). All three critiques argued that the importance of higher education was over-valued, and suggested that the book was silent on how to engender critical action and critical self-reflection.
Crème (1999) suggested that the critical being be nurtured from an early age and argued for the development of skills through a critically reflective approach using critical thinking in its broadest sense to foster an on-going way of being. She expanded on
Barnett’s (1997) wider interpretation of critical thinking and extended the idea into the domain of action as well as the domain of thought to develop new ways of seeing the world. Creme put flesh on Barnett’s philosophical model by examining a successful undergraduate, theme-based critical reading course using Death as the interdisciplinary structure and death journals as the tool. Critical being may be an idea whose time has come in the development of the future counsellor and the individual who comes to therapy for help.
181
A New Definition of the Critical Being
Both Facione (1998) and Barnett (1997) advocated the replacement of CT as a concept with a more holistic notion of a critical being that cultivates a critical spirit, not just as a means to an end, but as part of the goal itself as a liberating force in education, and a powerful resource in one’s personal and civic life. Facione in his philosophical essay targeted professional counsellors and included a definition of the critical thinker as described below:
…Habitually inquisitive, well-informed, trustful of reason, open-minded, flexible,
fair-minded in evaluation, honest in facing personal biases, prudent in making
judgements willing to reconsider, clear about issues, orderly in complex matters,
diligent in seeking relevant information, reasonable in the selection of criteria,
focused in inquiry and persistent in seeking results which are as precise as the subject
and the circumstances of inquiry permit. (p. 14).
Lelwica (1999) in her recent book Starving for Salvation reflected on a spiritual malaise in adolescents struggling with such things as eating disorders. She advocated that the path to true health requires a shift in consciousness to a new mode of awareness that incorporates an awakening to the bigger picture and a different way of seeing. She suggested that the challenge of living fully “… in the midst of life’s pungent mixture of suffering and joy, disappointment and hope, injustice and freedom, knowledge and uncertainty … is to learn to fall in love with the poignancy of being alive rather than concentrate on the eradication of disease.” (p.126).
Lelwica’s (1999) recommendations incorporated being physically and mindfully aware of feelings, developing a critical awareness of the body, and acknowledging and
182
learning to understand the sociopolitical matrix of the environment. Being and staying healthy is not about getting rid of uncomfortable feelings of dissonance, grief or loss, but learning to embrace and use them in a transformative process as resources for questioning cultural ideals.
Where Does the Future Education of the Critical Person Lie?
Darling (2001) explored background information on a community of inquiry, what it would look like in practice, different perceptions of that image, and the struggles that could be involved in maintaining it. She argued that educators and instructors viewed inquiry as the central purpose whereas some students viewed mutual support as paramount. In exploring the idea of a community of inquiry the article concluded by considering whether teacher education should concentrate on a community of inquiry or a community of compassion. The former cultivates the intellectual virtues and understandings teachers should have, while the latter teaches them the value of nurturing children and adolescents. Her argument was that a compassionate community that supports individual flourishing could produce “… kinder, gentler individuals but not necessarily better learners” (Darling, 2001, p. 21).
Brookfield (1999) addressed the impact that adults had on college and university classrooms and how adults experienced life as a student. He concentrated on the visceral and emotional dimensions of learning as opposed to focusing mostly on cognitive processes. He also offered insight into the emotional and cognitive ebbs and flows of adult learning and underscored the value of peer learning communities. Walkner and
Finney (1999) endorsed the holistic development of both skills and knowledge for further development in outlook and capability.
183
Hickey and Hargis (2002) in Teaching Eighties Babies Sixties Sensibilities, offered up insight into the differences between the Sixties and the Eighties generations. These researchers suggested helping students understand how hierarchies of power and position shaped their assumptions and worldviews. Hickey and Hargis offered strategies to motivate students to question the taken for granted aspects of everyday life, and how to grapple with issues around power, privilege, politics, social change and pedagogy to encourage intellectual flexibility.
Strange (1992) in Beyond the Classroom, suggested that learning is not restricted to the classroom and suggested that memorable moments of thought, insight or discovery often happened elsewhere. Using three scenarios based outside the classroom, she examined the role of the informal curriculum in encouraging reflective thinking and argued that a reflective judgement model became more important. Strange also suggested that the distinction between in- and out-of-class learning was an artificial one. She ultimately argued for exposure to modes of reflective thinking that were more complex and sophisticated than ones currently held and considered the role of learning styles within a learning cycle using a convergent learning style model.
Reimann and Bosnjak (1998) suggested that it was not sufficient to offer content information but that critical thinking had to be supported by carefully designed instructional activities. Santos and De Oliveira (1999) implied that CT was a higher order thinking skill that only appeared when students were trained based on specific sub-skills and related instructional activities. Santos and De Oliveira also suggested that new media without any instructional functions could not successfully promote CT and that being critical about something and having some tools available, did not guarantee CT.
184
March (2000) focused attention on picking links intentionally to highlight some lenses through which to view information that promoted the achievement of specific learning goals. The article specifically addressed how to generate greater and more subtle
CT through cognitive-dissonance. Newman et al., (1996) found that using a discussion format resulted in better critical thinking because individuals experiences more learning opportunities than in traditional education courses. Newman et al., also suggested that multi-faceted learning support and combined learning experiences using collaborative learning generally delivered many different points of view.
How Will the Teaching of CT Evolve?
Facione (1990) in The Delphi Report Executive Summary, highlighted recommendations for developing CT, and considered the role of direct instruction and assessment of CT skills. The Delphi Study stressed the importance of assessment strategies for educators to measure CT in contrast to students’ domain-specific knowledge. The summary encouraged instructors to move away from teacher training to teacher education. The Delphi Study also suggested how to model CT, create the right atmosphere for nurturing CT, and how to foster the students’ confidence in their own powers of reason.
Brookfield (1997) in Assessing Critical Thinking, considered the assessment and process of CT using a pre- and post-test approach, an experiential approach, a behavioural approach, and a conversational approach based on a public commitment to and engagement in modelling CT. Brookfield advocated for educators shifting their focus to active learning by doing, and argued that CT was integral to the democratic process, may hold the promise of a universal theory for learning, and be a template for
185
experiential learning. Stressed was the importance of individuals learning to think, write and speak in critical and democratic ways by using a conversational approach and modelling teachers and leaders in positions of power and authority.
How to Improve Learning?
Astleitner (2002) argued that there was a greater need to offer individuals access to various types of learning environments and suggested a number of ways that instruction could be made more attractive including: (a) evaluating and designing existing instruction to be more relevant to their interests; (b) increase individual confidence in learning as well as satisfaction levels toward information; (c) break down the information into small weekly segments; and (4) provide clear criteria of expected performance and participation levels. Drop out rates were cut in half from 44% to 22% after implementing these recommendations. Visser (1998) disagreed and suggested motivational verbal or written communications concentrating on a support system where unexpected messages would gain attention, must be linked to feedback from a learners’ work to make individuals feel part of the group, engage them in the process, and provide feedback to enhance satisfaction.
Limitations
Although this review included a few articles that referenced learning beyond the classroom, most of the literature referenced the elite perspective of higher education. The whole topic area would benefit from further consideration of critical thinking and becoming a critical being. The discussion would be enhanced also by considering the opinions from individuals outside the education system and by researchers who are not
186
necessarily educators. At the time of writing, information from other sources was unable to be found.
Further research also needs to be done on learning style and stages of critical thinking related to developmental levels (Newman et al., 1996). However, the literature findings considered here were useful in conceptualizing, defining and evaluating critical thinking.
The literature illuminated the whole topic area by helping to understand where critical thinking fits into the grand scheme of things. The possibility of any negative impact from
CT was also unable to be found.
Observations
This literature review was important in understanding that Critical Thinking in concept and practice may be a topic that many of us think we know, few of us actually practice and even less of us manage to teach successfully (Alexitch & Page, 1996;
Facione, 1998; Walkner & Finney, 1999). Other research suggested that CT is being taught and practiced in both traditional and non-traditional environments (Newman,
Johnson, Cochrane & Webb, 1996).
The discussion of the critical thinking literature was important because it adds to the theoretical knowledge surrounding CT and highlighted a number of interesting avenues for further discussion regarding the education of the individual as a critical being. The discussion opened the door for endorsing a critical thinking being as a replacement of critical thinking as a concept. The review of the literature illuminated the critical thinker and offered insight surrounding Critical Thinking (CT). The whole exercise was useful in illuminating the problems and dilemmas faced within the education system by both
187
students and educators. These findings were also relevant and useful to parents, students, educators, counsellors, researchers and other stakeholders.
The literature review process identified some key researchers in the field, compared and contrasted a variety of research that had been conducted, and synthesized a number of complex avenues of inquiry. Considering the education of the critical thinker in a rapidly changing technological world and highlighting concerns for individuals across the board is important. The possibility of replacing critical thinking as a concept with a more holistic idea of a critical life that encompasses critical reason, critical self-reflection and critical action manifested in a critical spirit is an exciting proposition.
The literature highlighted the ideals of academic freedom, critical thinking and scholarship as the responsibility of everyone and that the education of the critical thinking person should start in Kindergarten and continue across the lifespan. Hopefully it allowed some advocates of critical thinking to appreciate differences while encouraging others to see the significance of more active learning and critical thinking activities both within the classroom and in other learning environments. Given the changes in technology and the increase of adult learners, it may be time to revamp the traditional critical thinking approach (Astleitner, 2002).
Much of the literature suggested a shift in focus from teaching what to think to how to think. Some of the literature argued that counsellors and participants at all educational levels must become more aware of the vision of education as a civilizing force and the value of a liberal arts education and acquiring knowledge across the board. Others argued that educators and counsellors should be prepared to initiate, support and model this
188
initiative with the right atmosphere and incentives to support a strong working alliance which actively encourages experimenting with new approaches.
This review also emphasized that individuals need to take responsibility for their own learning and play an active role in developing their own critical thinking skills. Much of the literature argued that educators should be persuaded of the benefits of a CT emphasis by creating new evaluations and assessments of their own performance that would reward this new initiative while at the same time dissolve resistance to change. Most of the literature touched on the idea of overhauling the education system (Alexitch, 1996; APA,
1990; Astleitner, 2002).
The Delphi Study (1990) and Facione’s Executive Summary (1990) provided a strong background for the writer to understand the evolution, historical concepts, features and characteristics of CT plus a vision of the critical thinking person. These articles explored the importance of CT and why it counts, including concepts associated with CT and the acquisition of skills. Considering the education of the critical thinker from the perspective of the student and the teacher highlighted difficulties from both perspectives. Many of the articles also provided information on the instructional practices of teachers.
Most importantly, this chapter adds to the debate in the present while feeding into future research possibilities. The articles and books were chosen because they were good sources that considered critical thinking as a being, the education of the critical thinker, the role that traditional educators play, and a possible future course for the education of the critical thinking person (Astleitner, 2002; Barnett, 1997; Facione, 1990, 1998).This review suggested that critical thinking as a concept remains esoteric and elusive, is neither spontaneous nor automatic, and needs to be studied systematically and doggedly
189
in every circumstance, across situations, over time. Learning CT may be analogous to learning the ABC’s in that it should begin early in life, be part of the curriculum at the elementary level and continue across the lifespan both inside and outside the classroom.
The irony that true critical thinking was not utilized here because of limited understanding, time constraints, length of paper and the small body of evidence covered, is not lost on the writer. However, this body of research does allow inferences to be made, conclusions to be drawn, and adds to the big picture of what is known about the topic. If the critical thinker utilizes all domains to become wiser in an integrated way in both understanding and action as self, scholar and actor, considering a critical life seems an excellent place to start! The following chapter explores some of the concepts examined in this chapter related to developing a community of inquiry
190
CHAPTER X
Literature Review – Group Process
This chapter discusses the curative factors of group process and the benefits of using a group approach to therapeutic interventions. This information is important and relevant because it can provide information and guidance for facilitators on group process, identify expected results, delineate the impact on individuals, and set parameters for therapeutic interventions that reduce the potential for misuse or abuse to occur (Bates &
Johnson). Understanding the organization and utilization of groups and group dynamics can support the idea of a collaborative community that encourages the development of critical consciousness. This discussion is important in understanding how to enhance the facilitator’s role in teaching and guiding others, and also in assessing and understanding how individuals may function within this group program.
The Curative Factors of Group Process
The group process will be used to focus on individual strengths and to develop openness for considering that various people can look at something and see it differently.
The group process fosters greater connections and reconnections to family, friends, the larger society and the universe. Establishing a warm and supportive atmosphere for participants and developing a sense of group identification that facilitates assessment, understanding, planning and action towards set objectives is a worthy goal (Yalom,
2002).
Gibson and Mitchell (2003) suggested that groups are a natural venue for the emergence of unfolding processes where humans can have their basic, personal and social needs met because humans are group oriented and “… built to complement, assist
191
and enjoy each other…” (p. 181). Gibson and Mitchell define a group as “A number of individuals bound together by a community of interest, purpose and function.” (p. 189).
Human life unfolds within a script, geared to a timeframe or according to a storyline and group process incorporates the documentation of personal experience. The interview process, transcribing, reading, listening, creating and focusing on one’s own and others’ stories enriches the entire process. By building bridges between past and present, one’s own story and the shared journey with others, the group process cultivates an expanded self-identity and impetus for new life. Particularly, if individuals have regrets or a sense of unresolved issues group work can be seen as a second chance to refine and/or revise scripts for living.
Gibson and Mitchell (2003) also suggested that an understanding of the organization and utilization of groups and group dynamics can enhance the facilitator’s role in teaching and guiding others, and also in assessing and understanding how individuals function. Groups may be more effective for some people and some situations than individual counseling for exposing, learning or copying behavioural patterns, coping styles, values and adjustment techniques (Gibson & Mitchell). Bates and Johnson (1972) suggested that group processes can be helpful when provided skillfully or they can be hurtful when they are misused. Knowing the type of group process being offered, identifying the expected results, delineating the expected impact on members, and setting the parameters for therapeutic interventions reduces the potential for misuse or abuse to occur (Bates & Johnson).
Irving Yalom (2002) suggested that groups are used for counseling purposes, not just because it is more efficient or cost-effective but because groups involve beneficial
192
resources and possibilities that can be mobilized to facilitate development and solve problems of living. He referred to these resources and possibilities as curative factors because participants often begin to identify with the group in a cohesive way that allows them to feel supported and to be supportive.
The old cliché of “A burden shared is a burden halved” expresses one of the important premises for members to express concerns and feelings in a supportive environment that has a cathartic effect. As time goes by participants often begin to identify with the group, be more willing to open up, experiment and undertake challenges in a more wholehearted way (Yalom, 1995, 2002).
Another very important aspect is the imitation, interpersonal learning and social skills that can be learned vicariously from the facilitator and other group members, particularly when there are common themes or problems. Listening and observing others can prove insightful. People can also imitate a particular attitude, try on a new style of coping, practice social skills, or adopt a new frame of reference.
Groups are helpful to members for sharing information on techniques for coping, and disseminating information and education to a captive and receptive audience. Groups can help to manage stress, resolve issues and get things done. Knowing that others have similar feelings or experiences is often a relief because individuals do not need to feel isolated, abnormal or overwhelmed. Group work also helps to normalize and demystify experiences so that individuals can deal more effectively and directly with problems
(Gibson & Mitchell, 2002).
The group can generate a powerful sense of hope that can be instilled in others and be utilized as a catalyst for change and a source of inspiration (Gibson & Mitchell, 2002,
193
Yalom, 2002). Groups can also provide a safe and comfortable space in which people may find new ways of learning, have their better qualities reinforced and gain valuable insights on being. One of the most potent aspects of the group process is in terms of a philosophical sense of a higher purpose. There is an altruistic opportunity to contribute to the wellness of others through advice, encouragement and insights that often benefit the person who gives (Yalom).
For the facilitator this group process provides the courage to let go of the need to always speak authoritatively and it provides patience to allow the shared spirit of inquiry to wind its way into conversation, revealing truth in its own time. I trust that when I have something to say I will be compelled to speak my understanding of truth. Through faith in the process, the truth will be spoken, but not always by me. Believing in this process allows me to journey into the intellectually unknown, knowing that I will eventually arrive at a point of understanding, a place of personal authority and meaning-making where an emerging understanding of self is held together in relationship (Yalom, 2002).
A non-judgemental stance can also encourage clients to reveal themselves more fully and enhance both the therapeutic and group bond (MacDougall & Arthur, 2001). Clients need to feel that they have been listened to, taken seriously and validated. This knowledge is useful in overcoming negative self/group conceptions, recognizing and resisting negative social pressures, and fostering positive group identities in both interpersonal and intrapersonal dynamics (MacDougall & Arthur).
Effective probes and pertinent questions are helpful to stimulate group conversation and interactions in exploring individual attitudes and the importance that language has in any exchange (MacDougall & Arthur, 2001). Such an approach is helpful in identify
194
underlying dissonance in a client’s thinking and behaviours, racial identity statuses, and levels of cognitive and effective readiness related to their family of origin’s beliefs and values (MacDougall & Arthur).
This chapter was important for understanding many of the curative factors associated with group work in terms of vicarious learning and developing strategies and skills to manage life issues and accomplish goals from other group participants. Particularly, understanding the altruistic benefits of participating in group process, the importance of viewing the group as a separate entity, and the impact of group dynamics. The discussion was also helpful in viewing group work through a less directive approach by allowing the group to develop and function in a more organic process. A kind of management from behind approach which is advocated in this group program.
195
CHAPTER XI
Synthesis
Summary
More than a century ago, the philosopher Friedrich Nietzsche suggested that Man’s world has been invaded with science, technology and culture – God is dead! (Friedrich
Nietzsche Society, 2003). For those who believe that we cannot be good without God the future is intriguing and scary. Our parents could not imagine a world in which everyone did not go to church and belong to a service club (fifty years ago six in ten of us attended church on Sunday, now it is two in ten), (Statistics Canada, 2003). Nowadays, it is hard to imagine a world where only a handful of people read a daily newspaper and care enough to vote (fifty years ago 75% of citizens voted, now it is less than 60%), (Statistics
Canada, 2003). Young Canadians are half as likely to go to church, read a newspaper or vote (Statistics Canada, 2003).
Some individuals could take the pessimistic view that society has become more detached and disengaged from religious and civil institutions that have traditionally given meaning to the lives of previous generations (Armstrong & Armstrong, 2003; Pettifor,
2001). Others may see society as devoid of ideals or ethics and its citizens no longer believing in societal values, with no faith that participation in politics or civic life will make a difference. Other people might suggest that it is a society that is non-ideological, non-judgemental and disengaged from social institutions and traditional ethical and religious values with no belief in a government system, country or tribe worth fighting for. Relationship does not include leadership, citizenship, or community.
196
It conjures up a society made up of people who want to go with the flow, or be chameleons in search of hedonistic pleasures that allow detachment from things that cannot be controlled. If Pipher (1994) is right, much of the media perpetuates the notion that the biggest decisions being faced by some individuals is whether to use pills or drugs to alter ephemeral moods, or whether to have Botox, chip implants or laser surgery to change identity. Hierarchies are irrelevant because they cannot be relied upon, nothing is permanent, everything is in flux, and life is an unending exploration of all the micro- pleasures in the world. Everything is experimental and sensorial in a search for peace, calm, Zen. Hell is restricted to boredom in this life as opposed to eternal damnation in the next.
So, what happens in a society that may not value good citizenship or where ethical dilemmas end in a shrug or a “whatever”? Are eating disorders and the like just manifestations of a much bigger problem? At the back of many of our minds there is a nagging suspicion that as Westernized societies become more secular and less reliant on religious beliefs such as life after death, and the family unit buckles under attack, the idea of community has little meaning for many people. There is also a sense that strong family support systems are disappearing and a worry that our senses are being overwhelmed by a distorted or sensationalized media information technology, pharmacology and/or digital world.
I am unconvinced that the average adolescent who is struggling with an eating disorder (or any other problem for that matter), is motivated to look at the bigger picture when they are having difficulty getting from A to B. The existential idea that life is finite, death is a fact, and learning to live with a certain level of anxiety may not be a sign of
197
pathology but the corollary of a worthwhile existence, tends to be lost on many adolescents. Contemplating such abstract concepts as the meaning of life, existence, essence, nihilistic nothingness, meaninglessness, beliefs, values, self-reflectance, mythology or ruminating on loneliness, alienation, power struggles or aloneness need not dwell on teenage angst as a central concern. Not everyone needs to look into the great abyss to reach the “Aha!” moment that some people would say is necessary to be able to live life fully in the here and now.
Spirituality, creativity or critical consciousness need to be presented as celebrating the magic of the universe and going out into the world with courage to generate a blueprint for how to live life. Adolescents on the cusp of adulthood need to be convinced to create the life they should be living by indulging their unique human consciousness and creativity to bring a sense of meaning to their lives and to add value. These young people should be encouraged to think and talk in symbols, self-relate, and use their creativity and imagination to the fullest. Teenagers need to fall in love with living the optimistic life, taking responsibility for their own being and its Dasien notion of becoming (Miller &
Cook-Greuter, 2000; Walsh, 1990a, 1990b, 1999a, 1999b; Walsh & Vaughan, 1993).
All adolescents should be encouraged to focus on self-awareness, to believe in building authentic relationships, to have faith in their choices, and to have the confidence to dream the impossible dream. A search for meaning using simple and clear language and relatively simple propositions to guide, understand and explain many of life’s deepest issues should be used to further the notion that humans need to take courage to live in the present, that life requires commitment but has no guarantees, and that insight comes with
198
recognizing awareness is imperfect (May & Yalom, 2000; Walsh, 1990a, 1990b, 1999a,
1999b; Walsh & Vaughan, 1993).
Adolescents need to cultivate a strong sense of themselves and their place in the world, and to have roots that provide them with some stability in times of crisis.
Teenagers would benefit by having their better qualities reinforced, identifying with things that give them a sense of pride, and focusing on what makes them feel a sense of belonging as part of a larger universe. As Pipher (1994) stated “Strong girls know who they are and value themselves as multifaceted people” (p. 320). They can envision themselves becoming whatever they choose which sustains them under pressure. Helping adolescents to find continuity between their past and current lives and helping them to believe in their creative talents will give them hope for the future and boost their self- esteem.
Encouraging adolescents to live life soulfully builds strength of character that helps them to believe that they are useful and have things to offer family, friends and community. Teenagers can be encouraged to think that, even if they are distancing as part of the individuation process, they should keep talking, seek contact and stay connected in important ways (Pipher, 1994). Through all the chaos of adolescence they should be encouraged to hold onto their faith in themselves and the significant people in their lives.
This approach allows adolescents to learn to live with the joy of being in the moment while supporting the development of the individual, fostering the development of identity and promoting individuation, separation and maturation without sacrificing relationship
(Walsh, 1990a, 1990b, 1999a, 1999b; Walsh & Vaughan, 1993).
199
If adolescents understand how they think, what their beliefs and values are, they can be shown assertive ways to resist outside pressures to be ultra-feminine, to go with the flow, or be part of a clique. Teenagers can cultivate that inner fortitude and critical consciousness so that, when push comes to shove, they can stand up for themselves
(Pipher, 1994; Walsh, 1990a, 1990b, 1993, 1999a, 1999b). By developing passions and stress relieving habits that cultivate their critical and creative potential, they can learn strategies to fortify them in times of adversity that will help them fight efforts to limit their value (Pipher, 1994).
These young females can be shown heroic examples of individuals (particularly women) who share some of their common experiences, yet went on to overcome adversity when they were rejected, isolated or lonely as adolescents. In Smart girls, gifted women, Kerr (1985) studied the experiences of strong women as adolescents and found that they had similar stories to tell about being rejected and socially isolated because they were smart, or not quite attractive enough. Kerr suggested that many of these successful women developed a protective coating and safe space so that they could continue to grow and change without being viscerated. Through reading books, staying close to family, having faith, cultivating their creative passions, caring for others, and finding their voice, individuals can develop a system that allows them to see the girl poisoning aspects of the culture without being defeated by them (Pipher, 1994).
For instance, adolescent girls should know that healthy and adaptive functioning includes taking time to integrate into the social scene, withdrawing for a while, or acknowledging that one is not ready to drink or be sexual (Pipher, 1994). While they are trying to define themselves, taking responsibility for their choices, and crystallizing the
200
kind of individual they would like to become, Pipher suggested the weak often look strong and the strong often look weak. “The girls who seem the happiest in junior high are not often the healthiest adults …they may be the girls who have less radar to pick up signals about reality … or be the girls who don’t even try to resolve contradictions or make sense of reality.” (p. 323).
It is also important not to give too much air time to the truncated notion of women as helpless victims, or politicizing the therapeutic process along gender lines. Given that we are dealing primarily with adolescent girls, it is easy to think in terms of Feminist psychotherapy which arose out of the fusion of feminist sociology, psychology and critical theory which has a bit of a radical element similar to what developed with
Psychoanalysis (Taylor, 1991). A model that stresses inequality is working from the perspective of exclusion and stresses and reinforces difference which, in my mind, limits the opportunity for self-knowledge to occur.
While I believe that understanding personal, political and cultural issues around power are necessary, fixating on lack of power issues feeds into this sense of adolescents suffering from masochistic character disorders or narcissistic tendencies which can perpetuate a victim mentality (Taylor, 1991). The idea of the princess and the pea syndrome where girls keel over in a strong wind or thinking of adolescent females as hothouse plants that will wither and die on the vine with the least amount of pressure or stress is both patronizing and insulting (Pipher, 1994).
Adolescents need to hear that a vision for the future may be a new Canadian generation of young women who are part of a new vanguard marked by values of tolerance for diversity, social justice and adaptability to a complex world. These young
201
women need to hear that more than any other demographic group, young women identify the Charter of Rights and Freedoms as a symbol of their pride in Canada and theirs is the only group in which a majority opposes capital punishment (Statistics Canada, 2003). In a survey by the Centre of Research and Information in Canada, it shows that young women in their early twenties are most strongly opposed to racism and discrimination, and they are striking in their numbers that approve same-sex marriages (Status of
Women, 2003).
Adolescents struggling with an eating disorder need to embrace many of the feminist core tenets such as empowerment and social interest and hear that many young women are already paving this new way. They also need to hear that they are the largest group ever in human history and there is power in numbers should they choose to use it
(Statistics Canada, 2003; Status of Women, 2003). It bodes well for their future.
In the end, decisions about solutions involve fundamental choices around core values and social harmony is cultivated by providing a justice system for all that incorporates a shared core value system. Adolescents need to know what is just, cultivate assertiveness and have the courage to stand firm and ask for what they need so that they feel worthy of self-respect. These young women also need to believe and have faith in moral communities that do not function on exploitation or self-interest, but look to honour and reinforce the virtues that each individual brings to the table as part of a just society
(Pettifor, 2001). Adolescents girls need to hear and understand that they are stepping into a culture that in so many ways seems made for them. The future is friendly!
A spiritual perspective can help individuals interpret the events of life and the framework of spiritual belief may form the basis for how people make decisions in
202
personal and health matters that ultimately motivate behaviour. A spiritual foundation may be a powerful means of coping in times of difficulty and illness. Although the decision to pursue spiritual endeavours is a matter of choice, health professionals and practitioners should know the importance of spirituality in the lives of the people they serve to effectively work with the whole person. The literature confirmed the paucity of educational guidance resources that use practical, hands-on, guidance approaches to teach and nurture spirituality without ties to a specific religious perspective.
It is important to help individuals find meaning in their lives, to offer them a forum to express unmet spiritual needs, and to support them in finding solutions to daily hassles.
Another important goal of this group program is to help these individuals find supportive people with whom they can openly discuss their issues, to offer information and education in a format that makes sense to them, in language that they can understand.
There is, however, some unease about reducing therapeutic interventions to a manual or guide which can imply a kind of lock-step approach to treatment. Although the need for flexibility has been stressed in this process there is always a danger of it being seen as more of an idiographic or idealistic approach to treatment - an over generalization or over simplification of a very complex issue. Wilson (1996) suggested that manuals are perceived as interfering with therapist/client relationships, the building of therapeutic rapport and as extinguishing the intuitive qualities of therapeutic work.
Le Grange and Lock (2004) however, argued that related to anorexia nervosa a treatment manual for this population could provide a focus for the treatment process, help to set appropriate treatment goals, provide timeline interventions, codify the efficacy and experience of treatments, and help to provide an overall structure for the treatment
203
process. LeGrange and Lock also suggested that a manual may be necessary for follow- up systematic research studies to allow for consistent application of interventions across individuals. Using a guide allows for treatment interventions which are less dependent on the characteristics of individual therapists and allows for interventions to be replicated across sites and settings.
Throughout this project, I have worried about being capable and knowledgeable enough to do no harm, and have considered at some length whether a cognitive/behavioural approach to psychoeducation could successfully be combined with art therapy. So much of what I had read previously seemed to indicate that these paradigms might be diametrically opposed. The former often being considered more measurable and scientific, the latter, not scientific enough!
Hopefully, this study will add to the theoretical debate on the importance of spirituality in individuals’ lives and dispel the notion that understanding and discussing spirituality should be wedded to specific religious beliefs. The underlying premise behind this process disputes the notion that spiritual resources can only be accessed when individuals need pastoral or palliative care and should be sectioned off from the rest of an individual’s life. This project also highlights how the world’s religious needs are changing and asks health care professional to consider how best to incorporate spiritual elements into existing psychoeducational resources to fit the needs of a multicultural
Canadian society in an increasingly secular age.
I have tried not to commit the sin of hubris through arrogance or ignorance by railroading my own agenda or discounting others’ intellectual contributions in my attempt to do justice to a huge topic area such as spirituality. Leaving the discussion of
204
spirituality in the hands of theologians, Academia, or religious leaders to be dispensed only when individuals need pastoral or palliative care, or assuming that the evolution of spiritual development is akin to osmosis, strikes me as rather shortsighted!
Therapeutic interventions in any of these major topic areas has been shown to be helpful. Psychoeducational information can make a difference just on its own. Yet intuitively, I sense that combining these together under one umbrella may hold even greater potential. The next step would be to conduct these types of workshops under more controlled conditions with pre- and post-tests to truly assess the benefits of these types of workshops. Also to examine the potential negative effects of creativity which was beyond the scope of this paper. New technological and medical discoveries related to neurogenesis and mind-body medicine hold great promise for understanding the health promoting affects of combining novelty, numinosity and creativity (Schilder, 1948;
Rossi, 2002). As I said earlier, a community of enquiry that begins in Kindergarten and continues across the lifespan to develop the critical being seems a great place to start!
205
CHAPTER XII
References
Abrahim, S., & Llewellyn-Jones, D. (1992). Eating disorders: The facts (3rd ed.). Oxford,
England: Oxford University Press.
Abrams, K. K., Allen, L. R., & Gray, J. J. (1993). Disordered eating attitudes and behaviours,
psychological adjustment and ethnic identity: A comparison of black and white female
college students. International Journal of Eating Disorders, 14, 49-57.
Agell, G. (1998). Special feature: Janie Rhyne’s dissertation drawings as personal constructs:
a study in visual dynamics. American Journal of Art Therapy, 36(4), 115-125.
AlAteeqi, N. & Allard, J. (2001). Anorexia Nervosa: From starvation to re-feeding. Clinical
Nutrition, 3(1), 1-6.
Alexander, K. C. (1991). Art making: Bridge to metaphorical thinking. The Arts in
Psychotherapy, 18, 105-111.
Alexitch, L., & Page, S. (1996). Problems in higher education: Dilemmas for Canadian
students in the Nineties. Guidance & Counseling, 11(2), 15-19.
Allen, P. (1992). Artist in residence: An alternative to “clarification” for art therapists.
Journal of the American Art Therapy Association, 9(1), 22-29.
Allen, P. (2001). Art therapists who are artists. American Journal of Art Therapy, 39(4), 102-
109.
206
Alter-Muri, S. (1996). Dali to Beuys: Incorporating art history in art therapy treatment plans.
Journal of the American Art Therapy Association, 13(2), 102-107.
American Academy of Pediatrics (2003). Identifying and treating eating disorders.
Pediatrics, 111(1), 204-209.
American Philosophical Association. (1990). Critical thinking: A statement of expert
consensus for purposes of educational assessment and instruction “The Delphi report”.
Committee on Pre-College Philosophy. (ERIC Document Reproduction Service No. ED),
315-423.
American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental
Disorders. (4th ed., DSM-IV). Washington, DC: Author.
Anderson, J. W. (2001). Sigmund Freud’s life and work: An unofficial guide to the Freud
exhibit. Annual of Psychoanalysis, 29, 9-25.
Ansbacher, H. L. (1990). Alfred Adler’s influence on the three leading co-founders of
humanistic psychology. Journal of Humanistic Psychology, 30(4), 45-54.
Ansbacher, H. L. (1997). Adler’s place today in the psychology of memory. Journal of
Personality, 15(3), 197-209.
Apter, N. (2003). The human being: J. L. Moreno’s vision in psychodrama. International
Journal of Psychotherapy, 8(1), 31-36.
Arlow, J. A. (2000). Psychoanalysis. In Raymond J. Corsini & Danny Wedding (Eds.),
207
Current Psychotherapies. (6th ed.). Chapter, 2 (pp.16-53). Illinois: Peacock.
Armstrong, P., & Armstrong, H. (2003). Wasting away (2nd ed.). Ontario: Oxford Press.
Arthur, N., & Stewart, J. (2001). Multicultural counseling in the new millennium:
Introduction to the special theme issue. Canadian Journal of Counseling, 35, 3-14.
Acharya, M., Wood, M. J. M., & Robinson, P. H. (1995). What can the art of anorexic
patients tell us about their internal world: A case study. European Eating Disorders
Review, 3(4), 242-254.
Astleitner, H. (2002). Teaching critical thinking on-line. Journal of Instructional
Psychology, 29(2), 53-77.
Barnett, R. (1997). Higher education: A critical business. Buckingham, England: University
Press.
Barr, T. C., Sharpe, T., Shisslack, C., Bryson, S., Estes, L. S., Gray, N., McKnight, K. A.,
Crago, M., Kraemer, H. C., & Killen, J. D. (1998). Factors associated with weight
concerns in adolescent girls. International Journal of Eating Disorders, 24, 31-42.
Bates, M., & Johnson, C. D. (1972). Group leadership: A manual for group leaders. Denver:
Love Publishing.
Baxter, H. (2001). Nibbles: Religion and eating disorders. European Eating Disorder
Review, 9(2), 137-139.
Beck, A. T. (1988). Love is never enough, (pp. 254-273). New York, NY: Harper & Row.
208
Beck, A. T. (1999). Prisoners of hate: The cognitive basis of anger, hostility and violence,
(pp. 249-259). New York, NY: Perrenial.
Bender, L. (1981). The creative process in psychopathological art. The Arts in
Psychotherapy, 8, 3-14.
Bercuson, D., Bothwell, R., & Granatstein, J. (1984). The great brain robbery. Toronto:
McLelland & Stewart.
Berry, J. W. (1997). Immigration, acculturation and adaptation. Applied Psychology: An
International Review, 46(1), 5-68.
Berry, J. W. (2001). A psychology of immigration. Journal of Social Issues, 37(3), 615-631.
Betensky, M. (2001). Phenomenological art therapy. In J. A Rubin (Ed.), Approaches to art
therapy: Theory and technique (2nd ed., pp. 121-133). PA: Brunner-Routledge.
Black, C. M. D., & Wilson, G. T. (1996). Assessment of eating disorders: Interview versus
questionnaire. International Journal of Eating Disorders, 20, 43-50.
Blake, W., Turnbull, S., & Treasure, J. (1997). Stages and processes of change in eating
disorders: Implications for therapy. Clinical Psychology and Psychotherapy, 4, 186-191.
Blatner, A. (1992). Theoretical principles underlying creative art therapies. The Arts in
Psychotherapy, 18(5), 405-409.
Blue, A. W., & Darou, W. G. (2002). Counseling and psychotherapy with First Nations.
Arthur and Collins.
209
Bowlby, J. (1973). Separation: Anxiety and anger. New York, NY: Basic.
Bowlby, J. (1979). The making and breaking of affectional bonds. London: Tavistock.
Bowlby, J. (1988). A secure base: Parent-child attachment and healthy human development.
New York, NY: Basic Books.
Borkman, T. J. (1999). Understanding self-help/mutual aid: Experiential learning in the
commons. New Brunswick, NJ: Rutgers University Press.
Brotman, A. W., Stern, T. A., & Herzog, D. B. (1984). Emotional reactions of house officers
to patients with anorexia nervosa, diabetes and obesity. Journal of Eating Disorder, 3,(4),
71-82.
Braxton, J. M., & Nordvall, R. C. (1985). Selective liberal arts colleges: Higher quality as
well as higher prestige. Journal of Higher Education, 56, 538-554.
Brewerton, T. D., Hand, L. D., & Bishop, E. R. (1993). The Tridimensional Personality
Questionnaire in eating disorder patients. International Journal of Eating Disorders, 14,
213-218.
Brigham, F. M. (1970). Masks as a therapeutic modality. The Journal of the American
Osteopathic Association, 69, 549-555.
British Columbia Ministry of Health and Ministry Responsible for Seniors. (1999). Guide to
The Mental Health Act, effective November 15, 1999.
Brookfield, S. D. (1997). Assessing critical thinking: New directions for adult & continuing
210
Education, 75, 17-30. College Student Journal, 34(3), 391-399.
Brookfield, S. D. (1999). What is college really like for adult students? About Campus,
3(6), 10-16.
Bruch, H. (1974). Eating disorders: Obesity, anorexia nervosa and the person within. New
York, NY: Basic.
Bruner (1990). Themes of grief. Nursing Research, 38, 354-358.
Bryant-Waugh, R., Knibbs, J., Fosson, A., Kaminski, Z., & Lask, B. (1988). Long term
follow-up of patients with early onset anorexia nervosa. Archives of Disease in
Childhood, 63, 5-9.
Bulik, C. M., Sullivan, P. F., Weltzin, T. E., & Kaye, W. H. (1995). Temperament in eating
disorders. International Journal of Eating Disorders, 17, 251-261.
Burkhardt, E. (1984). The works of William James. London: Harvard.
Camp, D. E., Klesges, R. C., & Relyea, G. (1993). The relationship between body weight
concerns and adolescent smoking. Health Psychology, 12, 24-32.
Canadian Psychological Association. (2000). Code of ethics. Retrieved May 20, 2004, from
http://www/cpa.ca/ethics2000.html.
Canadian Psychological Association (2001). Companion Manual to the Canadian Code of
Ethics for Psychologists (3rd ed.). Ottawa: Canadian Psychological Association.
Case, C., & Dalley, T. (1992). The handbook of art therapy (pp. 119-145). New
211
York, NY: Routledge.
Chanda, J. ( 1994). Multicultural education and the visual arts. Arts Education Policy Review,
94(1), 12-17.
Charpentier, P. (2000). Friend or foe? European Eating Disorders Review, 8, 257-259.
Cherry, D. (2000). Beyond the frame: Feminism and visual culture, Britain 1850-1900.
London: Routledge.
Cheung, C. K., Rudowicz, E., Kwan, A. S. F., & Yue, Z. D. (2002). Assessing university
students’ general and specific critical thinking. College Student Journal, 36(4), 504-
526.
Childress, A. C., Brewerton, T. D., Hodges, E. L., & Jarrell, M. P. (1993). The Kids’ Eating
Disorders Survey (KEDS): A study of middle school students. Journal of the American
Academy of Child and Adolescent Psychiatry, 32, 843-850.
Cirlot, J. E. (1993). A dictionary of symbols (2nd ed.). New York, NY: Barnes & Noble.
Colton, A. & Pistrang, N. (2004). Adolescents’ experiences of inpatient treatment for
Anorexia Nervosa. European Eating Disorders Review, 12, 307-316.
Congdon, K. C. (1978). Democratizing art therapy. The use of folklore in theory and
practice. In M. O. Jones (Ed.), Putting folklore to work. Lexington, KY: Kentucky Press.
Cooley, C. H. (1922). Human nature and the social order. New York, NY: Scribner.
Cooper, J. C. (1978). An illustrated encyclopaedia of traditional symbols. London: Thames
212
& Hudson.
Corey, G. (1985). Theory and practice of group counseling. California, CA: Cole Publishing.
Cormier, S., & Nurius, P. S. (2003). Interviewing and change strategies for helpers:
Fundamental skills and cognitive behavioural interventions. (5th ed.). Pacific Grove, Ca:
Brooks/Cole-Thomson Learning.
Corsini, J., & Wedding, J. (Eds.). (2000). Current Psychotherapies. (6th ed.). Illinois:
Peacock.
Cox, V. (1997). The other voice in early modern Europe. Chicago: University of Chicago
Press.
Cram, S. J., & Dobson, K. (1993). Confidentiality: Ethical and legal aspects for Canadian
Psychologists. Canadian Psychology, 34(3), 347-363.
Creighton, T. (1999). Spirituality and the principalship: Leadership for the new Millennium.
International Electronic Journal for Leadership in Learning, 3(11), 1-9.
Creme, P. (1999). A reflection on the education of the “critical person”. Teaching in
Higher Education, 4(4), 461-473.
Csikszentmihalyi, M. (1996). Creativity: Flow and the psychology of discovery and
invention. New York, NY: Harper-Collins.
Dahlke, R. (1992). Mandalas of the world: A meditating and painting guide. New York,
NY: Sterling.
Dana, R. H. (1998). Understanding cultural identity in intervention and assessment, (pp. 15-
213
34). Thousand Oaks, CA: Sage.
Darling, L. F. (2001). When conceptions collide: Constructing a community of inquiry
For teacher education in British Columbia. Journal of Education for Teaching, 27(1),
7-23.
Davidson, L., Chinman, M., Kloos, B., Weingarten, R., Stayner, D., & Tebes, J. K. (1999).
Peer Support among individuals with severe mental illness: A review of the evidence.
Clinical Psychology: Science and Practice, 6, 165-187.
Daya, R. (2001). Changing the face of multicultural counseling with principles of change.
Canadian Journal of Counseling, 35(1), 49-62.
De Bouvoir, S. (1952). The second sex. New York, NY: Knopf.
Denmark, F., & Paludi, M. A. (1993). Psychology of women. San Francisco: Greenwood
Press.
Dick, R. D. (1991). An empirical taxonomy of critical thinking. Journal of Instructional
Psychology, 18(2), 79-92.
Dickerson, V. C., & Zimmerman, J. L. (1995). A constructionist exercise in anti-
pathologizing. Journal of Systemic Therapies, 14, 33-45.
Doig, C., & Burgess, E. (2000). Withholding life-sustaining treatment: Are adolescents
competent to makes these decisions? Canadian Medical Association Journal, 162, 1585-
1588.
214
Dosamantes, E. (1992). Spatial patterns associated with the separation-individuation process
in an Adult long-term psychodynamically oriented movement therapy group. The Arts in
Psychotherapy, 19, 3-12.
Douglas, C. (2000). Analytical Psychotherapy. In Raymond J. Corsini, & Danny Wedding
(Eds.), Current Psychotherapies. (6th ed., Chapter 4, 99-132). Illinois: Peacock.
Dudek, S. Z., & Cote, R. (1994). Problem finding revisited. In M. A Runco, Problem finding,
Problem solving and creativity (pp. 130-150). Norwood, NJ: Ablex.
Duker, M., & Slade, R. (1988). Anorexia and Bulimia: How to help. Milton Keynes: Open
University Press.
Dunn-Snow, P., & Joy-Smellie, S. (2000). Teaching art therapy techniques: Mask-making, A
case in point. Journal of the American Art Therapy Association, 17, 125-131.
Eating Disorder Resource Centre of British Columbia (EDRC). (2005). Childrens’ and
Woman’s Hospital, Vancouver.
Elder, L., & Paul, R. (2001). Critical thinking: Thinking with concepts. Journal of
Development Education, 24(3), 42-46.
Elkins, D. (1999). Spirituality: It’s what’s missing in mental health. Psychology Today, 32,
44-48. Retrieved October 31, 2005 from
http:www.findarticles.com/cfo/m1175/532/55625500/p1/articlejhtml.
Erikson, E. (1968). Identity, youth and crisis. New York, NY: Norton.
215
Erricker, C. (2002). Critique and coherence in spiritual education. International Journal of
Children’s Spirituality, 7(3), 237-239.
Esses, V. M., & Gardner, R. C. (1996). Multiculturalism in Canada: Context and current
status. The Canadian Journal of Behavioural Science, 28(3), 145-152.
Facione, P. A. (1990). Critical thinking: A statement of expert consensus for purposes of
educational assessment and instruction “The Delphi Report,” Executive Summary.
Hilbrae, CA: Academic Press.
Facione, P. A. (1998). Critical thinking: What it is and why it counts. California Academic
Press, 1-16. Retrieved November 3, 2003 from http://www.abcounsellored.net.
Fairburn, C. G., & Beglin, S. J. (1994). Assessment of eating disorders: Interview or self-
report questionnaire? International Journal of Eating Disorders, 16(4), 363-370.
Fairburn, C. G., Norman, P. A., Welch, S. L., O’Conner, M. E., Doll, H. A., & Peveler, R. C.
(1995). A prospective study of outcome in bulimia nervosa and the long-term effects of
three psychological treatments. Archives of General Psychiatry, 52, 304-312.
Feinberg, J., & Shafer-Landau, R. (1999). Reason and responsibility. Readings in some basic
problems of philosophy. London: Wadsworth.
Fenton, W. N. (1987). The false faces of Iroquois. Norman, OK: University of Oklahoma
Press.
Festinger, L. (1954). A theory of social comparison processes. Psychological Review, 7, 117-
216
140.
Fisher, M., Golden, N. H., Katzman, D. K., Kreipe, R. E., Rees, J., Schebendach, J., Sigman
G., Ammerman, S. & Hoberman, H. M. (1995). Eating disorders in adolescents: A
background paper. Journal of Adolescent Health, 16, 430-437.
Flament, M. F., Godart, N. T., Fermanian, J., & Jeammet, P. (2001). Predictive factors of
social disability in patients with eating disorders. Eating and Weight Disorders, 6, 99-
106.
Fleming, J., & Schmukler, G. I. (1992). Attitudes of medical professional towards patients
with eating disorders. Australian and New Zealand Journal of Psychiatry, 26, 436-443.
Foucault, M. (1973). The order of things: An archeology of the human sciences.
New York: Vintage.
French, S. A., Story, M., Neumark-Sztainer, D., Downes, B., Resnick, M., & Blum, R.
(1997). Ethnic differences in psychosocial and health behaviour correlates of dieting,
purging and binge eating in a population-based sample of adolescent females.
International Journal of Eating Disorders, 22, 315-322.
Friedrich Neitzsche Society. (n.d.). Retrieved August 5, 2003, from
http://www.fns.org.uk/index.htm.
Frieden, B. (1964). The feminine mystique. New York: Norton.
Friedman, S. S. (1997). When girls feel fat. San Francisco: Harper Collins.
Fromm, E. (1955). The sane society. New York, NY: Holt, Rinehart and Winston.
Fryear, J. L., & Stephens, B. C. (1988). Group therapy using masks and video to facilitate
intrapersonal communication. The Arts in Psychotherapy, 15, 227-234.
Gambone, J. (2003). Finding what “spirits” you. The Clergy Journal, 5, 4-6.
217
Garner, D. M. (1991). The eating disorder Inventory-2: Professional manual. Odessa, Fl:
Psychological Assessment Resources.
Genius, S. (2003). Treating all patients with medicine and surgery alone is not scientifically
reasonable. Citizens Centre Report, 30(10), 81-83.
Getzels, J. W., & Csikszentmihalyi, M. (1976). The creative vision: A longitudinal study of
problem finding in art. New York, NY: Wiley.
Gibson, R. L., Mitchell, M. H. (2003). Introduction to Counseling and Guidance. (6th ed.).
Upper Saddle River, NJ: Pearson Education.
Gilbert, K. R. (2002). Taking a narrative approach to grief research: Finding meaning in
stories. Death Studies, 26, 223-239.
Gilligan, C. (1982). In a different voice. Cambridge, MA: Harvard University Press.
Gilligan, C. (1991). Women’s psychological development: Implications for psychotherapy.
In C. Gilligan, A. G. Rogers, and D. L. Tolman (Eds.). Women, girls & Psychotherapy:
Reframing resistance. pp. 5-31. New York, NY: Hawthorn Press.
Gilligan, C., Rogers, A. G., Tolman, D. (1991). Women, girls and psychotherapy.
Binghampton, NY: Haworth Press.
Gilman, R. (1978). Discovery of self through masks: an art therapy technique. Art Therapy:
Expanding Horizon, The American Art Therapy Conference proceedings, 148-151.
Goldberg, R. (1997). Ethical dilemmas in working with children and adolescents. In D. T.
Marsh & R. D. Magee (Eds.), Ethical and legal issues in professional practice with
families (pp. 97-111). Canada: Wiley & Sons.
Greiger, I., & Ponterotto, J. G. (1995). A framework for assessment in multicultural
counseling. In J. Ponterotto, J. M. Casas, L. A. Suzuki, & C. M. Alexander (Eds.),
218
Handbook of multicultural counseling (1st ed., pp. 357-374). Thousand Oaks, CA: Sage.
Gross, R. E. (1996). Feminism and religion. Boston: Beacon Press.
Gusella, J., Butler, G., Nichols, L., & Bird, D. (2003). A brief questionnaire to assess
readiness to change in adolescents with eating disorders: Its applications to group
therapy. European Eating Disorders Review, 11, 58-71.
Haas, P. F., & Keeley, S. M. (1998). Coping with faculty resistance to teaching critical
thinking. College Teaching, 46(2), 63-68.
Halpern, D. F. (1998). Teaching critical thinking for transfer across domains. American
Psychologist, 53, 449-455.
Hammond, M., & Collins, R. (1991). Self-Directed Learning: Critical Practice. London:
Kogan Page.
Hanes, M. (1997). Utilizing the circus phenomenon as a drawing theme in art therapy. The
Arts in Psychotherapy, 24, 375-384.
Hardman, R., & Berrett, M. (2001). Eating disorder recovery: A spiritual perspective.
Retrieved June, 22, 2005 from http://centerforchange.com/articles/spirit_1.html.
Harris, E. C., & Barraclough, B. (1997). Suicide as an outcome for mental disorders. The
British Journal of Psychiatry, 17, 205-228.
Hiebert, B. (1996). Using informal methods to assess client change. Guidance & Counseling,
11(4), 3-13.
Hiebert, B. (1996). Integrating evaluation into counseling practice: Accountability and
219
evaluation intertwined. Canadian Journal of Counseling, 31(2), 112-126.
Herpetz-Dahlmann, B., Wewetzer, D., Schulz, E., & Remschmidt, H. (1996). Course and
outcome in adolescent anorexia nervosa. International Journal of Eating Disorders, 19,
335-345.
Herpetz-Dahlmann, B., Muller, B., & Herpetz, S. (2001). Prospective 10-year follow-up in
adolescent anorexia nervosa – Course, outcome, psychiatric comorbidity and
Psychosocial adaptation. Journal of Child Psychology and Psychiatry, 42, 603-612.
Hertzog, D. B., Field, A., Keller, M., West, J., Robbins, W., Staley, J., & Colditz, G. (1996).
Subtyping of eating disorders: Is it justified? Journal of the American Academy of Child
and Adolescent Psychiatry, 35, 928-936.
Hickey, G., & Hargis, P. G. (2002). Teaching Eighties babies Sixties sensibilities.
Radical History Review, 84, 149-165.
Hillman, J. (1989). A blue fire. New York: Harper and Row.
Ho, D. Y. (1995). Internalized culture, culturocentrism and transcendence. The Counseling
Psychologist, 23, 4-23.
Horney, K. (1940). New ways to in psychoanalysis. New York, NY: Norton.
Horvath, A. O., & Symonds, B. D. (2001). Relation between working alliance and outcome
in psychotherapy: A meta-analysis. Journal of Counseling Psychology, 38, 139-149.
Hua, T. (1991). Herein lies the treasure trove (Volume 1). Kuala Lumpar: Dharma Realm
220
Buddhist University.
Hua, T. (2001). Buddhist terminology. Talmage, CA: Tze Yun Tung Temple.
Huges, C. (1997). Review of the book [Higher education: A critical business]. British
Journal of Sociology of Education, 20(1), 130-132.
Hull, J. M. (2001). Competition and spiritual development. International Journal of
Children’s Spirituality, 6(3), 263-275.
Hull, J. M. (2002). Spiritual development: Interpretations and applications. British Journal of
Religious Education, 24(3), 171-182.
Hull, J. M. (2003). A spirituality of disability: The Christian heritage as both problem and
potential. Studies in Christian Ethics, 16(2), 21-36.
Ibrahim, F. A. (1991). Contribution of cultural worldview to generic counseling and
development. Journal of Counseling and Development, 70, 13-19.
Ishiyama, F. I. (1995a). Use of validationgram in counseling: Exploring sources of self-
validation and impact in personal transition. Canadian Journal of Counseling, 29, 134-
146.
Ishiyama, F. I. (1995b). Culturally dislocated clients: Self-validation and cultural conflict
issues and counseling implications. Canadian Journal of Counseling, 29, 262-275.
Jacobson, E. (1954). The self and the object world: Vicissitudes of the infantile cathexes and
their influence on ideational and affective development. Psychoanalytic Study of the
221
Child, 9, 75-127.
Janzing, H. (1998). The use of the mask in psychotherapy. The Arts in Psychotherapy, 25,
151-157.
Johnson, D. R. (1991). The theory and technique of transformations in drama therapy. The
Arts in Psychotherapy, 18, 285-300.
Johnson, D. R. (1998). On the therapeutic action of the creative arts therapies: The
Psychodynamic model. The Arts in Psychotherapy, 25(2), 85-99.
Jones, K., Runco, M. A., Dorman, C., & Freeland, D. C. (1997). Influential factors in artists’
lives and themes in their art work. Creative Research Journal, 10, 221-228.
Jung, C. G. (1911/1956). The psychology of the unconscious. Revised as Symbols of
transformation. Collected works, 5. Princeton: Princeton University Press.
Jung, C. (1968). Man and his symbols. London: Picador.
Kahn, B. B. (1999). Art Therapy with adolescents: Making it work for school counsellors.
Professional School Counseling, 2(4), 291-300.
Kalarchian, M. A., Wilson, G. T., Brolin, R. E., & Bradley, L. (2000). Assessment of eating
disorders in bariatric surgery candidates: Self-report questionnaire versus interview.
International Journal of Eating Disorders, 28, 465-469.
Katzman, D. L., Christensen, B., Young, A. R., & Zipursky, R. B. (2001). Starving the brain:
Structural abnormalities and cognitive impairment in adolescents with anorexia nervosa.
222
Seminars in Clinical Neuropsychiatry, 6, 146-152.
Kay, S. (1991). The figural problem solving and problem finding of professional and semi-
professional artists and non-artists. Creativity Research Journal, 4, 233-252.
Kelly, A. (1991). They psychology of personal constructs (2 vols.). London: Routledge.
Kenny, N. P. (1997). Adolescents and medical decision-making. Pediatric and Child Health,
2, 13-16.
Kerr, B. (1985). Smart girls, gifted women. Columbus, Ohio: Psychology Publishing.
Kilbourne, J. (1999). Deadly persuasion. New York, NY: The Free Press.
Killick, S. & Allen, C. (1997). “Shifting the balance” – Motivational Interviewing to help
behaviour change in people with Bulimia Nervosa. European Eating Disorders Review,
5(1), 33-41.
Kirkpatrick, J., & Caldwell, P. (2001). Eating disorders. Toronto, Ontario: Key Porter.
Kleifield, E. I., Sunday, S., Hurt, S., & Halmi, K. A. (1994). The tridimensional Personality
Questionnaire: An exploration of personality traits in eating disorders. Journal of
Psychiatric Research, 28, 413-423.
Klein, S. B., Loftus, J., & Burton, H. A. (1989). Two self-referencing effects: The
importance of distinguishing between self-descriptiveness, judgemental and
autobiographical retrieval in self-referent encoding communication. Journal of
Personality and Social Psychology, 56(6), 853-865.
223
Knill, P. J. (1995). The place of beauty in therapy and the arts. The Arts in Psychotherapy,
22, 1-7.
Knill, P. J. (2001). The unlimiting limits: Principles of an “oeuvre-oriented” expressive arts
therapy. Poiesis: A Journal of the Arts and Communication, 24-29.
Knill, P. J., Barba, H. N., & Fuchs, M. N. (1995). Minstrels of soul: Intermodal expressive
therapy. Toronto: Palmerston Press.
Koepfer, S. R. (2000). Drawing on the spirit: Embracing spirituality in pediatrics and
pediatric art therapy. Journal of the American Art Therapy Association, 17(3), 188-194.
Kohut, H. (1984). How does analysis cure? Chicago: University of Chicago Press.
Kramer, E. (2001a). Art and emptiness: New Problems in art education and art therapy.
American Journal of Art Therapy, 40(1), 6-16.
Kramer, E. (2001b). Sublimation in art therapy. In J. A Rubin (Ed.), Approaches to art
therapy: Theory and technique (2nd ed., pp. 28-39). New York, NY: Brunner-Routledge.
Kramer, E. (2002). On quality in art and art therapy. American Journal of Art Therapy, 40,
218-222.
Kreipe, R. E. 1(989). Short stature in females with anorexia nervosa. Pediatrics, 25, 7A.
Kristeller, J. L., & Hallett, B. C. (1999). An exploratory study of meditation based on
intervention for binge eating disorder. Journal of Health Psychology, 4, 3.
Kriz, J. (1999). On attractors – The teleological principle in systems theory, the arts and
therapy. Poiesis: A Journal of the Arts and Communication, 24-29.
224
Kuehnel, D. J. (1998). The co-constitution of knowledge issues from qualitative research
interviews. Paper presented at the Eighth International Human Research Conference,
University of Aarhus, Aarhus, Denmark.
Landgarten, H. B. (2001). Art Therapists who are artists. American Journal of Art Therapy,
39(3), 81-84.
Landy, R. (1984). Puppets, dolls, objects, masks, and make-up. Journal of Mental Imagery,
9(4), 43-56.
Landy, R. (1998). Establishing a model of communication between artists and creative arts
therapists. The Arts in psychotherapy, 25(5), 299-302.
Lask, B., & Bryant-Waugh, R. (1995). A European perspective on eating disorders. Journal
of Adolescent Health, 16, 418-419.
Le Grange, D., & Lock, J. (2004). The dearth of psychological treatment studies for Anorexia
Nervosa. International Journal of Eating Disorders, 37(2), 79-91.
Leichner, P., Brown, M., Atkinson, S., Henderson, R., & Jacek, C. (2001). Adolescents
suffering from eating disorders. Abstract obtained from St. Paul’s Hospital British.
Leichner P., & Manley, P. (2003). Anguish and despair in adolescents with eating disorders:
Helping to manage suicidal ideation and impulses. Crisis, 24(1), 32-36.
Lelwica, M. M. (1999). Starving for salvation. New York: Oxford University Press.
Leventhal, J. (1993). Maskmaking: A creative approach to adolescents in distress. In E.
Virshup (Ed.). California art therapy trends. Chicago: Magnolia Street.
Levine, S. K. (1994). The second coming: Chaos and order in psychotherapy and the arts.
Journal of the creative and expressive arts therapies exchange, 4, 1-8.
225
Levine, E. (1995). Tending the fire: Studies in art, therapy and creativity. Toronto, ON:
Palmerston Press. Part II: pp, 49-83.
Levine, M. P., Smolak, L., Moodey, A. F., Shuman, M. D., & Hessen, L. D. (1994).
Normative development challenges and dieting and eating disturbances in middle school
girls. International Journal of Eating Disorders, 15, 11-20.
Lewis, P. (1993). Creative transformation: The healing power of the arts. Wilmette, Ill:
Chiron.
Liebmann, M. (2004). (2nd ed). Art therapy for groups: A handbook of themes and exercises.
New York, NY: Routledge.
Linesch, D. G. (1988). Adolescent art therapy. New York, NY: Brunner & Mazel.
Litt, I. F. (1995). Shrinking bodies; Shrinking resources: Management of adolescents with
eating disorders. Journal of Adolescent Health, 16, 476-480.
Luzzarro, P., & Gabriel, B. (2000). The creative journey: A model for short-term group art
therapy with posttreatment cancer patients. Journal of the American Art Therapy
Association, 17(4), 265-269.
McCormick, R. (1996). Culturally appropriate means and ends of counseling as described by
First Nations people of British Columbia. International Journal for the Advancement of
Counseling, 18, 163-172.
MacDougall, C., & Arthur, N. (2001). Applying racial identity models in multicultural
counseling, Canadian Journal of Counseling, 35, 122-136.
McIllmurray, M. B., Francis, B., Harman, J. C., Morris, S. M., Soothill, K., & Thomas, C.
(2003). Psychosocial needs in cancer patients related to religious beliefs. Palliative
Medicine, 17, 49-54.
226
McNiff, S. (1981). Ethics and the autonomy of images. Arts in Psychotherapy, 18, 277-284.
McNiff, S. (1998). The shaman within. The Arts in Psychotherapy, 15, 285-291.
McNiff, S. (1989), Depth psychology of art. Springfield, Ill: Thomas. Chapter 4 – pp. 93-118.
McNiff, S. (1991). Ethics and the autonomy of images. Arts in Psychotherapy, 18, 277-284.
McNiff, S. (1998). Art-based research. London: Kingsley.
McNiven, H., & McNiven, P. (1994). Making masks. London: Wayland.
Mace, M. A. (1997). Toward an understanding of creativity through a qualitative appraisal
of contemporary art making. Creativity Research Journal, 10, 265-278.
Mace, M. A., & Ward, T. (2002). Modeling the creative process: A grounded theory analysis
of creativity in the domain of art making. Creativity Research Journal, 14(2), 179-192.
Mack, J. (1994). Masks and the art of expression. New York, NY: Abrams.
Maher, M. F., & Hunt, T. K. (1993). Spiritual reconsidered. Counseling and Values, 38, 21-
28.
Mahler, M., Pine, F. F., & Bergman, A. (1975). The psychological birth of the human infant.
New York, NY: Basic Books.
Maloney, A. (1999). Preference ratings of images representing archetypal themes: An
empirical study of the concept of archetypes. Journal of Analytical Psychology, 44, 101-
117.
Manley, R. S., & Leichner, P. (2003). Anguish and despair in adolescents with eating
disorders: Helping to manage suicidal ideation and impulses. Crisis 2003, 24(1), 32-36.
Manley, R. S., Rickson, H., & Standeven, B. (2000). Children and adolescents with eating
disorders: Strategies for teachers and school counselors. Intervention in School and
227
Clinic, 35(4), 228-231.
Manley, R. S., Smye, V., & Srikameswaren, S. (2001). Addressing complex ethical issues
in the treatment of children and adolescents with eating disorders: Application of a
framework for ethical decision-making. European Eating Disorders Review, 9, 144-166.
Manley, R. S., & Standish, K. (2005). Should adolescents with eating disorders be allowed to
exercise? The Renfrew Perspective, 3, 17-20.
March, T. (2000). Link like you mean it! Selecting WEB sites to support intentional
learning outcomes. Multimedia Schools, 7(2), 52-57.
Maslow, A. H. (1968). Towards a psychology of being (2nd ed.). Princeton, NJ: Van
Nostrand.
Maslow, A. H. (1970a). Motivation and personality (2nd ed.). New York, NY: Harper &
Row.
Maslow, A. H. (1970b). Holistic Emphasis. Journal of Individual Psychology, 26, 39.
May, R., & Yalom, I. (2000). Existential Psychotherapies. In R. J. Corsini & D. Wedding
(Eds.). Current Psythotherapies, (6th ed., Chapter 9), 273-302. Illinois: Peacock.
Mead, A. R. (1930). Supervised student teaching. New York: Johnson.
Mead, M. (1949). Men and women. New York, NY: Morrow.
Mead, M. (1971). Coming of age in Samoa. New York: Morrow.
Merali, N. (1998). Resolution of value conflicts in multicultural counseling. Canadian
228
Journal of Counseling, 33(1), 57-66.
Merton, T. (1958). Thoughts in solitude. New York, NY: Farra, Straus & Cudahy.
Mertens, D. M. (1998). Research methods in education and psychology: Integrating diversity
with quantitative & qualitative approaches. Thousand Oaks, CA: Sage.
Michalec, P. (2002). A calling to teach: Faith and the spiritual dimensions of teaching.
Encounter, Education for Meaning and Social Justice, 15(4), 1-14.
Miller, A. (1981). The drama of the gifted child. New York, NY: Basic.
Miller, C. (1993). The effects of art history-enriched art therapy on anxiety, time on task, and
art product quality. Art Therapy: Journal of the American Art Therapy Association,
10(4), 194-200.
Miller, W. R. (1983). Motivational interviewing with problem drinkers.
Behavioural Psychotherapy, 11, 147-172.
Miller, M. E., & Cook-Greuter, S. R. (2000). Creativity, spirituality and transcendence:
Paths to integrity and wisdom in the mature self. Stamford, Conn.: Ablex.
Miller, W., & Milliken, R. (2002). Pushing the experiential edge in therapy, training and
supervision: A case study of Create Therapy Institute’s experiential supervision program.
Poiesis: A Journal of Arts and Communication, 4, 80-89.
Miller, W. R. & Rollnick, S. (1991). Motivational Interviewing: Preparing people to change
addictive behaviours. New York, NY: Guilford.
229
Miller, W. R., Zweben, A., DiClemente, C. C., & Rychtarik, R. G. (1992). Motivational
enhancement therapy manual: A clinical research guide for therapists treating
individuals with alcohol abuse and dependence. Rockville, MD: National Institute on
Alcohol Abuse and Alcoholism.
Moon, B. L. (1998). The dynamics of art as therapy with adolescents. Springfield, Ill:
Thomas.
Moore, T. (2004). Dark nights of the soul: A guide to finding your way through life’s ordeals.
London: Gotham Books.
Moreno, J. L. (1987). The essential Moreno. In J. Fox (Ed.). New York, NY: Springer.
Mosak, H. H. (2000). Adlerian Psychotherapy. In R. J. Corsini & D. Wedding (Eds.),
Current Psychotherapies. (6th ed., Chapter 3, pp. 54-98). Ilinois: Peacock.
Myers, D. (1995). Psychology. (4th ed.). New York, NY: Worth.
Naumburg, M. (1987). Dynamically oriented art therapy: Its principles and practice (2nd Ed.,
pp. 1-25). Chicago: Magnolia Street.
Naumburg, M. (2001). Spontaneous art in education and psychotherapy. American Journal of
Art Therapy, 40(1), 46-64.
Nead, L. (1990). Myths and sexuality: Representations of women in Victorian Britain.
Oxford: Blackwell.
Nelson-Jones, R. (2002). Diverse goals for multicultural counseling and therapy. Counseling
230
Psychology Quarterly, 15(2), 133-144.
Neumark-Sztainer, D., Story, M., Falkner, N. H., Beuhring, T., & Resnick, M. D. (1999).
Sociodemographic and personal characteristics of adolescents engaged in weight loss and
weight/muscle gain behaviours: Who is doing what? Preventive Medicine, 28, 40-50.
Newman, D. R., Johnson, C., Cochrane, C., & Webb, B. (1996). An experiment in group
learning technology. Evaluating critical thinking in face-to-face and computer supported
seminars. Interpersonal Computing and Technology, 4, 57-74.
Newmark, G. (2004). Spiritual hunger. Health at Every Size, 88-89.
Nicholls, D., Chater, R., & Lask, B. (2000). Children into DSM don’t go: A comparison of
classification systems for eating disorders in childhood and early adolescence.
International Journal of Eating Disorders, 3, 317-324.
Osborn, C. J. (2001). A visual encapsulation of Adlerian theory: A tool for teaching and
learning. Journal of Humanistic Counseling & Development, 40(2), 243-251.
Otto, R. (1957). The idea of the holy. (3rd ed.). London: Oxford University Press.
Page, S., & Remigio, J. (1991). Value orientations in Canadian university undergraduates.
Journal of Psychology and the Behavioural Sciences, 6, 160-166.
Patrick, C. 1937). Creative thought in artists. Journal of Psychology, 4, 35-73.
Pedersen, P. (1995). The culture-bound counselor as an unintentional racist. Canadian
Journal of Counseling, 19, 197-205.
231
Pelletier, K. (1995). Between mind and body: Stress emotions and health. In E. Goleman, &
J. Gurin (Eds.). Mind and body medicine: How to use your mind for better health, (pp.
18-28). New York, NY: Consumer Report Books.
Perkins, D. N. (1986). Knowledge as Design. Hillsdale, N. J.: Lawrence Erlbaum
Associates.
Pettifor, J. L. (1991). Are professional codes of ethics relevant for multicultural counseling?
Canadian Journal of Counseling, 35(1), 26-35.
Pettifor, J. (2001). Ethics: Virtue and politics in the science and practice of psychology.
Canadian Psychology, 37(1), 1-12.
Pettifor, J. (2002). Ethics and multicultural counseling. Handout from a seminar held July,
2003, at University of Calgary, Alberta.
Pincher, S. (1991). Creating mandalas: For insight, healing and self-expression. Boston:
Shambhala.
Pinderhughes, E. (1989). Understanding race, ethnicity and power. The key to efficacy in
clinical practice. New York, NY: The Free Press.
Pinzon, J. L., & Jones, S. (2003). Starving to be thin: Anorexia nervosa and bulimia nervosa
in adolescents. The Canadian Journal of Diagnosis, 2, 79-87.
Pipher, M. (1994). Reviving Ophelia. New York: Ballantine.
Poonwassie, A., & Charter, A. (2001). An aboriginal worldview of helping: Empowering
approaches. Canadian Journal of Counseling, 35(1), 63-73.
232
Pope, K. S., & Vasquey, M. J. T. (1998). Ethics in psychotherapy and counseling. (2nd ed.).
San Francisco: Jossey-Bass.
Prochaska, J. (1999). How do people change, and how can we change to help many more
people In M. Hubble, D. Duncan, & S. Miller (Eds.), The heart and soul of change (pp.
227-258). Washington, DC: American Psychological Association.
Prochaska, J. (2000). Change at differing stages. In C. Snyder & R. Ingram (Eds.),
Handbook of psychological change (pp. 109-127). New York, NY: Wiley.
Prochaska, J., DiClemente, C., & Norcross, J. (1992). In search of how people change:
Applications to addictive behaviours. American Psychologist, 47, 1102-1114.
Puttnick, E. (1997). Women in new religions. New York, NY: St. Martin’s Press.
Rachels, J. (1993). The elements of moral philosophy. (2nd ed.). New York, NY: McGraw
Hill.
Ramsey, M. (1997). Exploring power in multicultural counseling encounters. International
Journal for the Advancement of Counseling, 19(3), 277-291.
Rathner, G. (1998). A plea against compulsory treatment of anorexia nervosa patients. In W.
Vandereycken & P. Beaumont (Eds.). Treating eating Disorders: Ethical, legal and
personal issues. New York, NY: University Press.
Reimann, P., & Bosjnak, M. (1998). Supporting hypertext-based argumentation skills.
Retrieved, October 30, 2005, from
233
http://www.or.zuma.mannheim.de/bosjnak/publications/edmedia98/de fault.htm.
Reissman, C. K. (1993). Narrative analysis. Thousand Oaks, CA: Sage.
Remuda Ranch Programs for Anorexia and Bulimia Inc. (2005). The Remuda Review. The
Christian Journal of Eating Disorders, 4(2), 12-26.
Rhyne, J. (1996). The gestalt art experience: Patterns that connect. Chicago: Magnolia
Street.
Rhyne, J. (2001). The Gestalt approach to experience, art, and art therapy. American Journal
of Art Therapy, 40(1), 109-121.
Richards, P. S., Hardman, R. K., Frost, H. A., Berrett, M. E., Clark-Sly, J. B., & Anderson,
D. K. (1997). Spiritual issues and interventions in the treatment of patients with eating
disorders. Eating Disorders, 5(4), 7-14.
Riley, S. (1994). Adolescents and family art therapy. Journal of Child and Adolescent Group
Therapy, 4, 81-97.
Robbins, A., & Sibley, LK. (1976). Creative art therapy. New York, NY: Brunner Mazel.
Robin, A. L., Gilroy, M., & Dennis, A. B. (1998). Treatment of eating disorders in children
and adolescents. Clinical Psychology Review, 18, 421-446.
Roff, L. L., & Parker, M. W. (2003). Spirituality and Alzheimer’s Disease Care. Altheimer’s
Care Quarterly, October/December, 1-4.
Rogers, C. R. (1967). The process of the basic encounter group. In J. F. T. Bugental (Ed.),
234
Challenges of humanistic psychology (pp. 261-276). New York: McGraw-Hill.
Rogers, C. R. (1980). A way of being. Boston: Houghton Mifflin.
Rogers, N. (1993). The creative connection, (Chapter 1: pp. 11-25). Palo Alto, CA: Science
and Behaviour Books.
Rollnick, S., Heather, N., & Bell, A. (1992). Negotiating behaviour change in medical
settings: The development of brief motivational interviewing. Journal of Mental Health,
1, 25-37.
Rollnick, S., & Miller, W. R. (1995). What is Motivational Interviewing? Behavioural and
Cognitive Psychotherapy, 23, 325-334.
Rossi, E. (2002). Psychological genomics: Gene expression, neurogensis and human
experience in mind-body medicine. Advances in Mind-Body Medicine, 18(2), 9-31.
Sandy, K. J. (1998). Role of spirituality in the recovery of eating disordered women.
Unpublished doctoral dissertation, University of Victoria, Victoria, British Columbia.
Santos, L. M., & De Oliveira, M. (1999). Internet as a freeway to foster critical thinking
in lab-activities. Retrieved October 30, 2005, from
http://www.narst.org/conference/santosdeoliveira/santosdeoliveir a.htm.
Schilder, P. (1942). Mind: Perception and thought in their constructive aspects. New York,
NY: Columbia University Press.
Schulz, W. E. (2000). Counseling ethics casebook 2000. (2nd ed.). Ottawa: Canadian
235
Counseling Association.
Seid, R. P. (1989). Never too thin: Why women are at war with their bodies. New York:
Prentice Hall.
Serpell, L. (2000). “Anorexic thinking”: Cognitive processes in anorexia nervosa.
Institute of Psychiatry. London: University of London.
Serpell, L., Neiderman, M., Haworth, E., Emmanueli, F., & Lask, B. (2003). The use of the
pros and cons of Anorexia Nervosa (P-CAN) Scale with children and adolescents.
Journal of Psychosomatic Research, 54, 567-571.
Serpell, L., Treasure, J., Teasdale, J., & Sullivan, V. (1999). Anorexia: Friend or foe?
London: Wiley.
Serpell, L., Teasdale, J. D., Troop, N. A., & Treasure, J. (2004). The development of the P-
CAN, a measure to operationalize the pros and cons of Anorexia Nervosa. Retrieved May
22nd, 2005 from www.interscience.wiley.com.
Serpell, L., & Treasure, J. (2002). Bulimia nervosa: Friend or foe? The pros and cons of
bulimia nervosa. Retrieved August 10, 2002, from www.interscience.wiley.com. DOI:
10:1002/eat.10076.
Sheppard, G. W., Schulz, W. E., & McMahon, S. A. (2002). Canadian Counseling
Association Code of Ethics, retrieved July 2005 from http://www.ccacc.ca.coe.htm.
Shisslak, C. M., Crago, M., & Estes, L. S. (1995). The spectrum of eating disturbances.
236
International Journal of Eating Disorder, 18, 209-219.
Shisslak, C. M., Crago, M., McKnight, K. M., Estes, L. S., Gray, N., & Parnaby, O. G.
(1998). Potential risk factors associated with weight control behaviours in elementary and
middle school girls. Journal of Psychosomatic Research, 44, 3001-313.
Shovlin, K. J. (1999). Discovering a Narrative voice through play and art therapy: A case
study. Guidance and Counseling, 14(4), 7-12.
Siegal, H. (1988). Educating Reason. New York: Routledge. In P. F. Haas., & M. Stuart
(1998). Coping with faculty resistance to teaching critical thinking. College Teaching,
46(2), 63-68.
Sinclair, C., & Pettifor, J. (2001). Companion manual to the Canadian Code of Ethics for
Psychologists. (3rd ed.). Ontario: Canadian Psychological Association.
Sivin, C. (1986). Maskmaking. Worcester, MA: Davis.
Skelton, A. (1997). Review of the book [Higher education: A
critical business]. British Journal of Sociology of Education, 20(1), 130-133.
Smolan, R., Moffitt, P., & Naythons, M. (1990). The power to heal. New York, NY : Preston
Hall Press.
Smythe, W. E., & Murray, M. J. (2000). Owning the story : Ethical considerations in
narrative research. Ethics & Behaviour, 10(4), 311-336.
Stanley, P. D., & Miller, M. M. (1993). Short-term art therapy with an adolescent male. Arts
237
in psychotherapy, 20, 397-402.
Starratt, R. J. (1996). Transforming educational administration: Meaning, community and
excellence. New York, NY: McGraw.
Statistics Canada. (2003). Census families. Retrieved August 4, 2005, from
http://www/statcan.ca/Daily/English/030811a/htm.
Statistics Canada. (2003). Women in Canada. Retrieved August 4, 2005, from
http://www.swc-cfc.gc.ca/about/about_e.html.
Steinhausen, H. C., Boyadjieva, S., Griogotuiu-Serbanescu, M., & Neumarker, K. J. (2003).
The outcome of adolescent eating disorders. Findings from an international collaborative
study. European Child and Adolescent Psychiatry, 12, 91-98.
Stevens, A. (1998). Response to Pietikainen. Journal of Analytical Psychology, 43(3), 345-
356.
Story, M., Rosenwinkel, K., Himes, J. H., Resnick, M., Harris, L. J., & Blum, R. W. (1991).
Demographic and risk factors associated with chronic dieting in adolescents. American
Journal of Diseases of Children, 145, 994-998.
Strange, C. (1992). Beyond the classroom. Liberal Education, 78(1), 28-33.
Strohm, S. M., & Baukus, R. A. (1995). Strategies for fostering critical thinking skills.
Journalism and Mass Communication Educator, 50(1), 55-62.
Sue. D. W., & Sue, D. (1999). Counseling the culturally different: Theory and practice, (3rd
Ed.). New York, NY: Wiley & Sons.
238
Sullivan, H. S. (1953). The study of instinct. London: Oxford University Press.
Surgenor, L. J., & Snell, D. L. (1998). Nasogastric tube as a means of attempted suicide: A
case report. European Eating Disorders Review, 6, 212-215.
Sysko, R., Walsh, T., & Fairburn, C. G. (2005). Eating disorder examination-questionnaire as
a measure of change in patients with bulimia nervosa. International Journal of Eating
Disorders, 37, 100-106.
Tillich, P. (1948). The shaking of the foundations. New York, NY: Scribner.
Tapper, T. (1997). A review of [Higher education: A critical business]. British Journal of
Sociology of Education, 20(1), 133-136.
Taylor, M. (1991). How psychoanalytic thinking lost its way in the hands of men: The case
for Feminist psychotherapy. British Journal of Guidance & Counseling, 19(1), 93-103.
Tomm, K. (1989). Externalizing the problem and internalizing personal agency. Journal of
Strategic and Systemic Therapies, 8, 54-59.
Trevino, J. G. (1996). Worldview and change in cross-counseling. The Counseling
Psychologist, 24, 198-215.
Ulman, E. (2001). Art therapy: Problems of definition. American Journal of Art Therapy,
40(1), 16-27.
Vanzant, I. (1998). One day my soul just opened up: Forty days and forty nights toward
spiritual strength and personal growth. New York, NY: Firside.
Vandereycken, W., & Meermann, R. (1984). Anorexia nervosa: A clinician’s guide to
treatment. New York, NY: Gruyter.
239
Visser, L. (1998). The development of motivational communication in distance education
support. [Unpublished doctoral dissertation, University of Twente, The Netherlands].
Vogler. R. J. M. (1993). The medicalization of eating: social control in eating disorders
clinic. Greenich, London: JAI Press.
Wade, C. (1995). Using writing to develop and assess critical thinking. Teaching of
Psychology, 22(1), 24-28.
Wadeson, H. (1980). Art psychotherapy. New York, NY: Wiley & Sons.
Wadeson, H. (1995). The dynamics of art psychotherapy (2nd ed.). New York, NY: John
Wiley & Sons.
Wadeson, H. (2001). An eclective approach to art therapy. In J. A. Rubin (Ed.), Approaches
to art therapy: Theory and technique (2nd ed., pp. 306-317). Pasadena: Brunner-
Routledge.
Wadeson, H., Agell, G., Minar, V., & Bush, J. (1994). How will the profession of art therapy
change in the next 25 years? Responses by past award winners. Journal of the American
Art Therapy Association, 11, 26-32.
Walker, B. (1988). The woman’s dictionary of symbols and sacred objects. Sand Francisco:
Harper.
Walkner, P., & Finney, N. (1999). Skill development and critical thinking in higher
education. Teaching in Higher Education, 4(4), 531-544.
240
Walsh, R. (1990a). The spirit of shamanism. Los Angeles: Tarcher.
Walsh, R. (1990b). Asian Psychotherapies. In R. J. Corsini, & D. Wedding (Eds.). Current
Psychotherapies, (6th ed.). (Chapter 13 – pp. 407-444). Itasca, Ill: Peacock.
Walsh, R. (1999a). Essential spirituality: The seven central practices to awaken heart and
mind. New York, NY: Wiley.
Walsh, F. (1999b). Spiritual resources in family therapy. New York: Guildwood Press.
Walsh, R., & Vaughan, F. (Eds.). (1993). Paths beyond ego: The transpersonal vision. Los
Angeles: Tarcher.
Watts, R. E. (1996). Social interest and the core conditions. Journal of Humanistic Education
& Development, 34(4), 165-171.
Warson, E., & Zajac, T. R. (1999). A weekend seminar with Edith Kramer. American
Journal of Art Therapy, 37(3), 99-102.
Welch, S. L., & Fairburn, C. G. (1996). Impulsivity or comorbidity in bulimia nervosa. A
controlled study of deliberate self-harm and alcohol and drug misuse in a community
sample. British Journal of Eating Disorders, 20, 359-365.
Wharton, J. (1999). The connection between Jungian theory and arts therapy. Miami Shores,
Fl: Barry University Press.
White, M. (1995). Re-authoring lives: Interviews and essays. Adelaide, South Australia:
Dulwich Center.
241
White, M., & Epston, D. (1990). Narrative means to therapeutic ends. New York: Norton.
Williams, H. (1980). Short-term art therapy. American Journal of Art Therapy, 1, 1-20.
Wilson, G. T. (1993). Assessment of binge eating. In C. G Fairburn & G. T. Wilson (Eds.),
Binge eating: Nature, Assessment and treatment (pp. 227-249). New York: Guildford
Press.
Wilson, G. T. (1996). Treatment of bulimia nervosa: When CBT fails. Behaviour Research
and Therapy, 34, 197-212.
Wilson, G. T., Fairburn, C. G., & Agras, W. S. (1997). Cognitive-behavioural therapy for
bulimia nervosa. In D. M. Garner, P. E. Garfinkel (Eds.). Handbook of treatment for
eating disorders (2nd ed., pp. 67-93). New York, NY: Guilford.
Winnicott, D. W. (1953). Transitional objects and transitional phenomena. A study of the
first not-me possession. International Journal of Psychoanalysis, 34, 89-97.
Winnicott, D. W. (1971). Playing and reality. New York: Basic Books.
Winnicott, D. W. (1971a). Transitional objects and transitional phenomena. In D. W.
Winnicott (Ed.), Playing and Reality. (pp. 147-162). London: Tavistock.
Winnicott, D. W. (1971b). The use of an object and relating through identifications. In D. W.
Winnicott (Ed.), Playing and reality. (pp. 86-94). London: Tavistock.
Wonderlich, S. A., & Mitchell, J. E. (1997). Eating disorders and comorbidity: Empirical,
conceptual, and clinical implications. Psychopharmacology Bulletin, 33, 381-390.
242
Woodman, M. (1990). The ravaged bridegroom: Masculinity in women. Toronto: Inner City
Books.
Yalom, I. D. (1995). The theory and practice of group psychotherapy (4th Ed.). New York:
Basic Books.
Yalom, I. D. (2002). The gift of therapy: An open letter to a new generation of therapists and
their patients. New York, NY: Harper Collins.
Zerbe, K. (1993). The body betrayed: A deeper understanding of women eating disorders and
treatment. Carlsbad, CA: American Psychiatric Press.
243
APPENDIX A
The Guide
Current psychoeducational and art therapy programs with this population may be missing an opportunity to develop more closely an overarching Bio-Psycho-Social-
Spiritual model for therapeutic intervention that incorporates spiritual, creative, critical thinking, experiential and psychoeducational components under one nucleus. This project seeks to address these deficits in a series of group therapeutic workshops that foster development and understanding of spirituality, critical being and creativity through a cognitive, behavioural and expressive therapy approach.
The purpose of this guide is to allow a facilitator to run a group psychoeducational/art therapy program for eating disorder individuals that offers an expanded and more holistic approach to therapeutic interventions. The material presented can be used to develop his or her own group and/or form the basis upon which this group process can be structured using the methods, procedures and resources presented.
Alternative communication activities to overcome linguistic or cultural barriers for participants will include creativity and art history, using the senses, and tactile experiences such as drawing, self-expression, photographs, music and cultural-exchange games. Self-exploration exercises to identify feelings in a given circumstance, discussing how cultural norms and assumptions influence an individual’s experience, or helping find alternative ways of thinking could prove beneficial. Using indigenous spiritual paradigms and disciplines that include the use of historical, cross-cultural art experiences are valuable in breaking down linear thinking and opening up to a broader perspective
(McNiff, 1991, 1998; Walsh, 1990a, 1990b, 1999a, 1999b; Walsh & Vaughan, 1993).
244
How to View These Workshops
It is important to state at the outset that the management of eating disorders usually requires a multidisciplinary team that includes a primary care physician, nutritionist and mental health professionals who should communicate and confer regularly. These workshops are not meant to take the place of other forms of medical intervention, individual therapeutic counseling, individual art therapy (both directive and non- directive), family therapy, or other forms of psychoeducational workshops. They are another way to enhance the interventions that already exist. Observing and interacting with individuals in a group setting provides valuable insight for avenues to explore later in individual clinical counseling situations. Issues around starvation, refeeding, weight gain or maintenance have to be closely linked to interventions because one is unlikely to succeed without the other.
Critical and mindful practice generates the possibility of converting a sense of alienation into insights that foster a more purposeful way of being in the world. The latest scientific and technological discoveries of how humans function at the cellular level has confirmed what the ancient wisdom traditions, the great philosophers and theorists such as Carl Jung may have known intuitively - that the spiritual component of an individual’s life is important. Science and technology in mind and body medicine is now showing that novelty, numinosity and creativity can activate and generate gene expression to facilitate neurogenesis, the growth of the brain and healing through stem cell differentiation and maturation (Rossi, 2002). Incorporating creative elements that have universal appeal may also allow individuals to feel connected to the past, to reflect about
245
the present and to consider the kind of individual they might wish to become in the future.
In the following appendices the guide presents a series of spiritual topics, a list of art experiences, and a structure and format for sample sessions that a facilitator can choose to follow (or not). Ideas and suggestions presented here are not carved in stone and the psychoeducational resources recommended for inclusion are not to be considered exhaustive. Rather, the suggestions put forward here should be thought of as a fluid process where a facilitator can incorporate a more spiritual component into group process for this population as well as all or some of the ideas and notions of how the group process should unfold. Facilitators can use the themes and topics presented here in their entirety or choose to incorporate many of their own ideas. They are encouraged to be creative in how, in what order, and to what degree components are integrated into the group program.
Critical Questions and Considerations
According to Liebmann (2001) and Gibson and Mitchell (2003) there are a number of questions that a facilitator needs to consider when forming a group:
What type of group is it? Is the group open or closed?
What is the purpose of the group?
What is the targeted population?
What are the general goals and purpose of the group?
What screening and selection procedures will be used?
What are the group boundaries and ground rules?
What are the minimum and maximum numbers for the group to be successful?
246
Are there evaluation procedures and possibilities for members to give feedback?
What are the evaluation procedures to give feedback to each member? In what
ways? Formal or informal or a mix of both?
How will the group be marketed, or will it be marketed at all?
Therapist/Counsellor/Facilitator:
Does there need to be a co-therapist?
How will therapist supervision be done?
Is payment involved?
What are the insurance provisions?
Room:
Is the space suitable, does it have enough floor space and storage room?
How do you get access to the room?
Is the space suitable for discussion, is it private?
Is there access to running water for clean-up purposes?
Is the room wheelchair accessible?
Is there a designated smoking area (inside or outside)?
Is the room quiet?
Where is the First Aid box, do you need a panic button, who do you call in
emergencies?
Do you have access to a telephone or do you need a mobile telephone?
Where are the fire exists and where are the gathering points?
What are the safety and containment issues that need to be considered?
Time:
247
What is the most suitable time to run the group?
Does it fit with other activities in the space?
Is it day or evening sessions and how often will it meet?
How long is each segment and how will each session be structured?
What is the length of each session?
What activities come before and after the group?
Location:
Is the location suitable and easily accessible by public transportation?
Materials Required:
Paints – tempra, acrylic, water colour, liquid redimix in an assortment of colours.
Adolescents like iridescent, fluorescent, metallic and glitter paints and glue;
Gouache, paint thickeners and textured emulsions;
Utensils for holding paints and mixing them - trays, cups, palettes in varying sizes
from small to large;
Brushes (small, medium and large);
Sponges, rollers and different tools for making markings other than using brushes;
Dry media – pencils (various HB’s), charcoal, conte, graphite sticks, coloured
pencils, water color pencils, crayons (wax, water, oil, pastels), felt pens in various
colours;
Paper – newsprint rolls, large newsprint page (2’ x 3’), sugar paper, lining paper,
cartridge paper, grease proof paper, water colour paper, different colours;
Card stock in a variety of thicknesses and colours for three-dimensional work;
248
Clay – basic clay, thin or thick, air tight containers, a variety of clay tools for
cutting and carving, clay that is air dried, and if access to a kiln even better;
Modelling substances such as plasticene, coloured beeswax, fimo;
Collage materials such as coloured tissue, glitter, sequins, coloured sand;
Junk material for 3-D work such as paper mache, plaster, casts, boxes, wire,
pipecleaners, found objects;
Scissors (sharp and rounded), clippers, exacto knives, knives (selected with regard
to safety issues);
Adhesives – glue, glue stick, masking tape, cellotape, water proof tape, Blu-Tak;
Plastic sheets, rags, newspaper, paper towel;
Art smocks, old shirts to protect clothing (Liebmann, 2004).
Although the above list of materials is ideal, in reality one can function quite well with basic primary colour paints, a block of clay and a space that is less than ideal.
Type of Group
For the purposes of the workshops discussed here it is helpful to think of these groups as a cross between psychoeducational groups and encounter groups. Psychoeducational groups emphasize cognitive and behavioral skill development that focus on current life situations and interactions within the group related to a group theme (Gibson & Mitchell,
2003). Encounter groups, as defined by Carl Rogers (1967) are more therapy oriented and emphasize personal growth through the development and improvement of interpersonal relationships via an experiential group process.
There are few clear boundaries between group guidance and group counseling but a good way to help to define them is that the former emphasizes cognition and the latter
249
emphasizes affect. Given that some groups work well together and others may function in a more fragmented way, the counsellor might choose to switch between the two. Usually the former is relatively unstructured and the latter more highly structured.
Group Process
The workshops are split into six distinct processes. The initial part of the group process individuals come together and perform a ritual that builds group cohesiveness, allows each individual to centre themselves, and prepares individuals to do spiritually healing therapeutic work. In the second segment of the session an opportunity is provided to consider either a motivational or critical consciousness piece that again focuses on developing or connecting with who individuals are or their social world. The third segment fosters an open studio atmosphere where individuals are free to relax, let their imagination take over and participate in a creative process that often has historical and cross cultural links. The fourth segment of the process is debriefing about the creative process where individuals are encouraged to share their thoughts and creative ideas. The fifth segment comprises communal clean up. The final debriefing is a closing ritual where individuals are again asked to come together and consider the group proceedings and to internalize the process.
Screening Process
Sometimes there may be reasons for screening someone out of a group or where group work is contraindicated such as individuals who are extremely fragmented, expressing suicidal thoughts, or exhibiting psychotic, sociopathic or paranoid behaviours.
However, even in these cases group work can be helpful. For individuals struggling with psychosis particularly, group work that includes art therapy can be one of the few places
250
where they feel grounded enough to interact with other individuals in a positive way.
Unfortunately, males tend not to participate in these types of groups, not because they do not like the art process, but because they are usually outnumbered and feel intimidated.
Unless you have enough adolescent males to balance the group, or hold an all male group, this type of process should be adapted for males in individual therapy.
Construction of the Group
It is recommended that the Group (maximum of 12 participants) have weekly sessions lasting approximately 1.5 hours using a semi-structured, psycho-educational/experiential format led by a clinical psychologist and a second art therapy professional or psychology student in clinical training. The format would encourage the development of a therapeutic group process using spiritually based, critical thinking, creative and interactive, hands-on learning experiences. Individual components of each session would be structured in relatively short durational segments to be sensitive to possible memory and concentration deficits that may exist, and to prevent boredom. Structure is also in place to build and maintain safety and trust within the group. Adolescents would be referred by either a health care professional, their parents or through self-referral (Gusella, Butler, Nichols &
Bird, 2003).
Ideally, it would be most helpful if the group process could cater to the same individuals from start to finish, however, this is rarely practical in hospital and agency settings where attendance is not mandatory and therapeutic offerings are economically driven. Attendance cannot always be guaranteed so the process should be flexible enough to allow individuals to pick up where they left off or allow new individuals to be integrated into the group without too much disruption. New people coming into the group
251
can be viewed as an opportunity to reiterate salient points or have other individuals coach or mentor newer members.
Goals and Objectives of Group Work
Groups usually focus on a particular type of problem, whether personal, social, educational or vocational. Aristotle spoke of three kinds of knowing Thorea (observing),
Praxis (doing), and Poiesis (making). As has already been stressed in this discussion, this project seeks to combine these under one nucleus within group process. The following are major goals and objectives:
To develop relationships with other adolescents who are having similar
experiences;
To assist adolescents in socializing and becoming more tolerant and sensitive to
others’ beliefs and values and respect their differences;
To learn how to accept the consequences of their choices;
To find their own solutions to problems while at the same time accessing other
group members’ collective experience;
To practice new ways of behaving and being in the world (including improved
interpersonal skills) that can be transferred to everyday life in a supportive
environment;
To explore internal problems in a supportive atmosphere around such issues as
loss, isolation, frustration, anger, stress, control, pain, denial and dependency that
requires personal change as a result of low self-esteem, self-worth or other
barriers to solving problems, achieving goals and objectives and moving forward;
252
To explore external obstacles such as logistical or practical problems around living independently that may require reshaping or renegotiating environments;
Analyze the stages of the therapy process from the perspective of transpersonal paradigms and a contemplative spiritual context to cultivate an expanded self- identity and impetus for new life;
To learn to express concerns and feelings in a supportive environment that has a cathartic effect;
To share information on how to manage stress and practice new styles of coping;
To identify with the group in a cohesive way that allows participants to feel supported and be supportive;
To foster a sense of wellbeing from giving;
To normalize and demystify individual experience to deal more effectively and directly with problems around eating disorders.
To provide an opportunity to listen and observe others and to imitate and learn interpersonal and social skills;
To develop a respect for and tolerance for the ideas of others;
To emphasize the importance of developing a social support network for coping with issues;
To build bridges between past and present, between one’s own journey and the shared journey with others and to adopt a new frame of reference;
To develop an appreciation of the fine arts as a beneficial endeavour for therapeutic action;
253
To use creative projects to experience and celebrate the joy of the creative process
as a fundamental link to creative action;
To provide tools to navigate the unknown and to find meaning in their illness
using art, drama, writing, poetry, ritual, myth and mask-making;
To foster the ability to accomplish critical life tasks and overcome obstacles to
living more meaningful and productive lives;
To cultivate a sense of community and social responsibility through the group
process using creative art projects;
The intent with this group process is to incorporate more fully and systematically the curative factors associated with group dynamics. In the beginning, the process would emphasize orientation, support, warmth and acceptance. Later it would develop universality, imitation, interpersonal learning, social skills, altruism, and hope. The goal for adolescents would be to learn to analyze the situation critically, reason and think clearly, and embrace new ways of seeing and being in the world to improve their quality of life. An individual’s privacy and personal boundaries would be highly valued and they would be in charge of the type, and degree of their level of interaction (Yalom, 2002).
The process would move from information, to understanding, to practice and build from problem exploration, to self-awareness, to deliberation, decision-making and finally to action. A reflective and experiential program design would be used where people explore issues, refine skills, ask questions and solve problems in a warm, safe and trusting environment where the boundaries of confidentiality and ethics have already been set. The process would provide some challenging and provocative question and
254
answer periods where people can practice empathic listening and responding and become more competent in dealing with real life issues.
Ultimately, the process would hope to stimulate the transfer of what has been learned to one’s own life that would deepen the individual’s understanding of the meaning of life and freedom, the acceptance of the fragility of life, the role of choice, the benefits of community and communion, and the importance of values, interests, aspirations and creative action within the whole process. While a supportive group is usually helpful for everyone, the process is presented as being particularly helpful for individuals who feel anxious, depressed, empty, negative or uncreative (Luzatto & Gabriel, 2000). Although the primary issue is the eating disorder the central focus is not on the eating disorder directly. The eating disorder is deliberately downplayed and is given a subordinate role in terms of the overall thematic content. The spotlight is gently focused elsewhere.
To be successful the topics need to be relevant and anchored in issues that relate to each individual’s personal experience. Information should be disseminated through easy to read handouts on a wide range of topics from stress/anger management, coping styles, practical tips, resources, health habits that include videos and occasional expert testimony. Also included are the study of artists such as Arnheim, Botticelli, Cassatt,
Michaelangelo, Munch, Plath, Thomas, Van Gogh and Wilde (to name just a few) who have dealt with life and social issues through their creative work.
Formal activities would be de-emphasized and creative spontaneity that focuses on process rather than product would be stressed to foster creative development. The goals would include experiencing an epiphany or finding the “Eureka!” moment in self- discovery and self-awareness, offering an outlet for self-expression, changing attitudes
255
towards others, and as a transformational creative and spiritual journey. The biggest challenge would be providing parameters for a safe environment while at the same time providing a stimulating and creative atmosphere (Luzzatto & Gabriel, 2000).
Goals for the Facilitator
Important objectives, goals and benefits related to this project are listed below:
Health Care Professionals:
Creation of a “how to” workshop guide for health care professionals who are charged
with providing counseling/psychoeducation/art therapy to adolescents with eating
disorders.
To have health care professionals consider how to incorporate spiritual components
into their work in a more directed way so that it becomes a Bio-Psycho-Social-
Spiritual model for interaction.
To show helping professionals how to incorporate a more spiritual and critical
approach to both their personal and professional lives.
To show health care professionals the value of incorporating art therapy experiences
that have historical lineage and cross cultural links.
To further the debate on the value of incorporating a spiritual approach to health care.
To show step by step instructions on space, tools and equipment, timelines, further
readings.
To make health care professionals aware of literature on spirituality, adolescent eating
disorders, critical thinking, critical being, critical consciousness, art therapy,
creativity and groups.
256
To consider the curative factors of group interaction, shared art making and group
experience.
Goals for Adolescent Participants
The more important objectives, goals and benefits are listed below:
Adolescents with Eating Disorders:
To foster deeper connections between their own mind, body and spirit.
To foster greater understanding of their beliefs, values and strengths.
To develop openness to a supracultural awareness and acceptance of others beliefs
and values.
To foster greater connections and reconnections to family, friends, the larger society
and the universe.
To foster self, self-esteem, self-awareness, self-concept, self-reflection.
To allow adolescents to be in the moment.
To support the ego.
Foster the development of identity.
Promote individuation, separation and maturation.
To allow self-expression/self-actualization.
To confront irrational thoughts and beliefs.
Enhance the individuals motivation to cooperate in change;
To encourage the exploration of underlying psychological issues;
Provide historical permanence, objectification, a spacial matrix, and release of
physical energy;
Encourage the expression and interpretation of unconscious experience.
257
Through the group process foster greater awareness and show alternative ways of
being in the world.
To provide a forum to explore educational information and creative elements related
to psychotherapeutic models, tools and techniques to understand themselves, others
and their universe better (Gibson & Mitchell, 2003; McNiff, 1998; Moon, 1998;
Wadeson, 2001; Yalom, 1995).
It has also been my experience in working with adolescents suffering from eating disorders that one has to be careful about the way that spirituality is presented because individuals may initially misunderstand the role of spiritually based workshops. These young people may think that the facilitator is trying to change or replace their own (or their families) religious beliefs or they may have difficulty grasping abstract concepts.
This may mean initially taking out the word spirituality all together until they are more comfortable with their understanding of what that means. Perhaps using a different vocabulary to describe the purpose of the workshops such as “Create the life you want to live”, “Explore your beliefs and values” or “Develop a mindfulness approach to life”.
The Benefits of Group Therapy
Group therapy provides a deeper, more intense experience for people who often have adjustment, emotional or developmental needs (Gibson & Mitchell, 2003). Therapy groups are usually distinguished from general counseling groups by “…the length of time and the depth of experience for the individuals involved.” (p. 189). Participants are often individuals who are dealing with chronic and mental or emotional disorders that require major personality reconstruction, so the expectation is that the facilitator or therapist would require a higher level of training.
258
Adolescents and Group Therapy
Related to adolescents with eating disorders, research evidence has demonstrated a number of benefits of support from similar others such as a sense of being understood, reduced feelings of isolation, and feeling supported (Borkman, 1999). Different types of support such as non-verbal, emotional and practical interventions were found to be most helpful (Davidson, Chinman, Kloos, Weingarten, Stayner & Tebes, 1999). Individuals found the freedom to discuss their eating disorder was a tremendous source of relief because they no longer felt alone (Colton & Pistrang, 2004).
Research has also found some negative, concomitant consequences generated from comparing oneself with others such as competition to be thinner and the distress of witnessing others’ disturbing behaviours (Borkman, 1999; Colton & Pistrang, 2004;
Davidson et al., 1999). Some individuals found that being with others meant learning new bad habits not just about eating behaviours, but related to other self-harming options
(Colton & Pistrang). Seeing others in a distressed state can create fear and upset and be a hindrance to recovery, therefore, affects on adolescents with an eating disorder within the group process should be carefully considered because it may influence the road to recovery for better or worse (Colton & Pistrang).
Maximizing the supportive aspects of the relationships while minimizing the detrimental affects would be a major goal. These concerns also raise the question of whether to allow individuals into a group regardless of level of wellness or to consider individuals closer to the same degree of wellness along the spectrum of recovery.
Leaving the process relatively open-ended means that individuals who have further to go
259
in recovery have the opportunity of being helped by gaining motivation from others further along the recovery road (Colton & Pistrang, 2004).
Emphasis and central focus with these workshops is split between sensitivity and personal insight, and group process and progress. As the individual gradually relaxes, feels safe enough to drop some defenses and facades they should relate more directly to their own feelings, and come to understand themselves and their relationship to others more accurately so that they feel less threatened. Having individuals participate in an intake interview (Appendix C) so that they understand the benefits and possible limitations of the group process is beneficial
Guidance versus Counseling versus Therapy
To think of individuals as more resilient, less fragile and less able to be victimized by their biological inheritance focuses on strengths and abilities that enable individuals to be active in therapy, responsible for their own education and to make choices wherever possible for their own learning (Douglas, 2000). Given that understanding emphasizes learning and educational goals, and that I do not want to teach someone something at the expense of them figuring it out for themselves, it is important to distinguish between psychotherapeutic and educational approaches.
Gibson and Mitchell (2003) suggested that it is important to distinguish between group guidance and group counseling. The former is geared towards providing information and education through an organized and planned group activity usually as a proactive measure. The content focuses more on providing educational, personal or social information with a goal of providing individuals with accurate information that will help in making life plans and decisions. The latter is the adjustment of developmental
260
experiences provided in a group setting geared towards therapeutic goals such as character building, personal relationship skills, and values and attitudes (Gibson &
Mitchell).
Generally, therapy requires a client and therapist interaction while guidance is an exchange between a teacher and student. The two disciplines are similar in that both are rituals that require an exchange using a creative process requiring skills, commitment and competencies in respect to training and preparation. However, they are motivated towards separate goals. Educational goals are usually oriented towards skill acquisition, improvement and increased knowledge governed by a body that dictates the educational framework, while therapy focuses on a process of self discovery and understanding requiring both a client and therapist to work towards specific therapeutic goals (Corsini &
Wedding, 2000).
The key is not to protect individuals from experiencing unpleasant feelings but to help them understand and embrace these as opportunities to examine and change personal attitudes and behaviours, and relate more effectively to others in everyday life situations in a safe environment. In reality, cross fertilization in helping individuals cope with day- to-day hassles and problems occurs at three levels – guidance, counseling and therapy.
261
APPENDIX B
Methods and Procedures
The Role of the Counsellor/Facilitator
The role of the facilitator is discussed in this Appendix as a separate entity rather than being embedded elsewhere in the document because the success of this group program rests in large part on the personal and professional skills and abilities of the facilitator. It is helpful in crystallizing the issues that a facilitator needs to consider when running this type of group program.
This Appendix discusses the benefits of locating spiritual resources and the leadership skills required to function successfully including the relevance of developing a personal supracultural awareness, understanding the client’s worldview, providing a safe and sacred space, and developing the right learning environment. It also touches briefly on understanding power and control issues, staying focused on the intent of the group process, monitoring counter productive behaviours, adapting counseling to client expectations, and the dangers of over-rating or under-rating expectations.
Other topics discussed in this chapter relate to the value of using spiritual paradigms and art experiences with cross cultural links, and the philosophical differences associated with using an integrative versus an eclectic approach. The chapter concludes with discussion on the viability and benefits of using a co-therapist model given the difficulties of running a flexible group program such as this that also requires observing and recording group dynamics. While these issues are discussed to some degree elsewhere, they bear repeating here because they are at the heart of sound ethical practice using this type of group process.
262
Locating Spiritual Resources
To work ethically and effectively with the whole person, it is critical for health care practitioners (psychiatrist, psychologist, counsellor, art therapist) to know about the importance of spirituality in the lives of the people they serve. Incorporating a comprehensive spiritual assessment into a treatment plan to help an individual locate spiritual resources is an important objective. Health care providers should help the people they serve address their spiritual needs because spiritual traditions often become extremely important as a disease progresses and cognitive decline becomes more pronounced (Michalec, 2002). In a secular society such as Canada, helping people without established ties to a faith community locate spiritual resources may be the more important objective.
Leadership Skills
Corey (1985) suggested that there are important leadership skills that are important when conducting groups.
Active Listening. Paying complete attention, absorbing content, noting nonverbal clues, sensing underlying messages;
Reflecting. Conveying the essence of what a person says so that they are aware of it;
Clarifying. Focusing on the key underlying issues and sorting out confusing and conflicting feelings;
Summarizing. Briefly stating what has been discussed, felt and experienced;
Facilitating. Creating a safe environment, assisting members to express themselves openly, being encouraging and supportive and involving all members;
Empathizing. Being able to understand and express another’s experiences;
263
Interpreting. Offering possible explanations for verbal and behavioural expressions which are often helpful for overcoming an impasse;
Questioning. Asking appropriately timed what and how questions to enhance the experience;
Linking. Stressing the connections and similarities between group members;
Supporting. Knowing whether it will be helpful or hurtful to offer support to a group member;
Blocking. Knowing how to block counter productive group behaviours such as gossiping, invasion of privacy etc;
Diagnozing. Being able to identify symptoms, label behaviour and provide the appropriate intervention;
Reality Testing. Encouraging members to view their situations and alternatives realistically;
Evaluating. Continuously reviewing the dynamics of each individual and group;
Terminating. Knowing when and how to terminate.
Although this is a fairly daunting list, each therapist/counsellor should self-evaluate and reflect on these because the counsellor’s voice, energy level, attitude and concerns set the tone of the group. The leader needs to ask themselves important questions such as
- How can I best help this person? How far can I push this person even although it may be painful? What am I willing to risk to help this individual? What will my reaction be if this person breaks down?
As a leader how you interrupt an individual, when to draw someone out, how to handle uncomfortable or unpleasant situations are critical for maintaining group
264
cohesiveness and productivity (Corey, 1985). Leaders need to be aware of when the focus is on an individual or on a topic. Leaders also need to be aware of when focus is shifting, when someone or something is holding focus and when they need to intervene to shift or hold focus. Facilitators also need to know how they will deal with someone monopolizing or creating hostile interactions and how they will handle members who push other members to do therapeutic work. The leader can set the tone by suggesting that each individual focus on themselves and being firm with respectful guidelines. The individual is usually the best person to decide when they are ready to work (Corey).
Family, Cultural Values and Non-Verbal Cues
To foster growth and minimize harm counsellors should have knowledge of how the family functions, how different cultural groups understand their identity formation and how characteristics of counseling may clash with the values of some cultural groups.
Counsellors should also know a variety of verbal rapport building skills and be able to read non-verbal cues such as gaze, visual behaviour, gesture and understand the meaning of interpersonal space and proxemics (MacDougall & Arthur, 2001). Keen attention to these details gives the facilitator a way to monitor the emotional intensity of the topic or subject matter in the group.
Innate Worth of Human Beings
Counsellors need to recognize the innate worth of human beings and not discriminate on the basis of race, culture, ethnicity, colour, status or personal characteristics (Canadian
Psychological Association, 2001). Individuals can be helped to recognize their own personal worth and uniqueness by mobilizing inner resources, expanding cultural
265
competencies, and affirming their identity and sense of belonging which generates the freedom of feeling safe internally (Trevino, 1996).
Research by MacDougall and Arthur (2001) showed when counsellors understood identity statuses, their interactive nature and their impact on counsellor behaviour, both rapport and interventions were enhanced. If the counsellor gives too much power to an individual’s shortcomings it takes away from faith in their own abilities and strengths.
Helping people appreciate their good qualities is also a way of counteracting the fear that can eat away at a participant’s security (MacDougall & Arthur).
The Right Learning Atmosphere
If guidelines are clear, reinforced often so that they understand what is expected of them, adolescents are more likely to take responsibility and participate in their own learning. Individuals are less likely to be distracted or disruptive because a supportive learning environment has been provided where they feel personally motivated to learn in a way that fits their specific needs. If emphasis is placed on a non-competitive atmosphere that fosters self-reflection and self-evaluation, it will in turn create self- reliance, more independence and greater creativity without negative labeling.
Be Prepared, Organized and Flexible
In facilitating learning in others it is usually helpful to work hard while making it look easy. Being knowledgeable, coming prepared, being able to articulate, speak and write in plain language are all necessary tools for the job. To speak distinctly or succinctly, to have the ability to read your audience and be innovative and creative when necessary. Being self-deprecating and funny at appropriate times can be indispensable attributes. Showing a passion for the arts, being genuinely interested in other people’s
266
learning and offering lots of encouragement will go a long way! It is also helpful to share one’s own knowledge and wisdom (such as it is) when asked, to help break down barriers. If you do those things well it generates interest in others and creates a good learning environment. Most of all, therapists have to be willing to listen to others’ perspectives - really listen!
The onus is on the facilitator to be more knowledgeable about both subject matter and how individuals learn. What is no longer acceptable is to talk at individuals. However, if you know anything about teenagers, this is definitely the wrong approach! In some respects this approach is harder and it places more demands on the facilitator because they have to be willing to be flexible and be able to react in unforeseen and unanticipated circumstances. Counsellors need to respond quickly and effectively to the changing needs of adolescents without it becoming disjointed, or affecting priceless teaching moments.
Good facilitators capitalize on building organization into a more flexible program, being knowledgeable, enthusiastic and innovative and knowing the best motivating devices in any given situation to grab an individual’s attention. Different ways for individuals to understand the information (verbal, visual, visceral, anecdotal, sensory) should be offered so that they use their own judgement and examine outcomes that help them to be motivated to learn.
Monitoring Counter Productive Behaviours
Monitoring is more than a passive function because the counsellor can block patterns of communication that are counter productive such as non-facilitative speech patterns, excessive questioning, gossiping or over-intellectualization. Both cognitive and experiential models can be used to guide the process, monitor the functioning level of
267
group members, bring items to the attention of individual’s awareness, and present possible alternative suggestions. Traffic directing tools (such as ego states or the Johari window can be used to block gossip and other non-productive interactions (Bates &
Johnson, 1972). Facilitators should know the differences that exist between other forms of healing and be able to articulate their professional limitations. Misuse occurs when counsellors are unclear or inadequately trained to distinguish between types of groups
(Bates & Johnson).
Stay Focused on Intent
When members of the group become disillusioned or are emotionally hurt or when the group disintegrates into an unplanned mix of guidance, counseling, and therapy, it verges on an unethical use of the process and the blame lies squarely on the facilitator’s shoulders. When the group leader specifies the parameters of the group, the desired results, keeps a clear vision of where the group is headed, and monitors the group’s progress toward reaching the established objectives, the therapist and the individual can leave at the end of the day feeling successful about their achievements and be motivated to return and participate further the next time.
Adapting Counseling to Client Expectations
Daya (2001) indicated that flexibility is predicated on a comprehensive knowledge in all the processes counsellors/therapists would plan to use, as well as the ability to enact a broad repertoire of skills. Facilitators must feel extremely comfortable adapting their style of counseling to match the client’s expectations and comfort levels. Group leaders cannot become fixated on using one theoretical model, or adopting a narrow style or application of interventions. The therapist must be sensitive to the risk of unspoken
268
factors becoming a barrier to the therapeutic alliance and the change process while at the same time be on guard against giving clients what they think they need (Trevino, 1996)!
The focus is client-centred, using knowledge and competencies in a variety of theories and techniques that embrace Western approaches to healing as well as less formal spiritual, creative and innovative ways of indigenous peoples and Eastern philosophies (Arthur & Stewart, 2001; Chanda, 1994). Increasing flexibility may lead to a renewed sense of hope and enthusiasm that can be used as the impetus for achieving personal goals (Sue & Sue, 1999).
It is also important to remember that individuals who are at a low body weight may find it difficult or impossible to engage in psychological work. Critically important is that the expectation of the facilitator for each individual member is not over or under-rated otherwise there is the possibility of coming across as patronizing, or worse, pushing individuals beyond their limitations. When confronted with an impasse or block, it is important for facilitators to know the impact of moving on to something new instead of sticking with something that will perhaps produce lasting change. Flexibility does not mean throwing away theoretical constructs or replacing knowledge, skills and awareness.
Integration Versus Eclecticism
Counsellors must also believe in the efficacy of a varied approach and be comfortable with interventions that cut across theories and belief systems but there are some pitfalls with this approach that need to be avoided (Arthur & Stewart, 2001; Greiger &
Ponterotto, 1995; Ho, 1995). Daya (2001) alluded to the danger of knowing a little bit of this and a little bit of that and suggested that the level of skills, knowledge and global
269
awareness of the counsellor are crucial for deciding on a flexible approach rather than a more structured one.
Facilitators must be willing to craft a more defined, integrative approach with theories that fit together and do not conflict, and be wary of adopting any given technique that fits at any given moment to avoid a kind of eclecticism run rampant with counsellors unwilling or unable to recognize their limitations. The level of flexibility should be inversely related to level of experience, otherwise there is a danger of eschewing established theoretical foundations in favour of becoming the equivalent of a personal guru, crystal ball gazer or mind reader.
Unifying Discourses
Given that cultural and value differences have been cited as potential sources of conflict between individuals and among groups, counsellors have an obligation to develop a non-racist identity of self as cultural beings. Practitioners should avoid cultural encapsulation and linear thinking by developing attitudes that demonstrate both respect for, and comfort with diverse groups within society. Group facilitators must believe in the healing power of the creative art therapy process using this model, have faith in the specific treatment practices used, and have knowledge of and be committed to, the spiritual group practice approach. Facilitators also need to focus on unifying discourses without marginalizing certain kinds of belonging and citizenship that may perpetuate discrimination and stigma.
As Marion Woodman (1990) suggested, if men and women are to become equal partners without resorting to a blame game, the foundations for a full partnership must first be laid within the individual. Unfortunately, when most of us look within we often
270
find an inner patriarchy where the male and female are polarized in a negative way.
These inner victims and tyrants need to be discarded so that a new more loving and fruitful relationship can come into being where masculine and feminine co-exist in a symbiotic relationship that transforms both (Woodman). Mirroring a way of being in the world that does not present with a truncated sense of wholeness may be the best gift a facilitator can give these young adolescent women. Woodman suggested patriarchy should be viewed as a mutual tragedy and that it is pointless to point fingers or spend time discussing whose fault it is or who has suffered more.
Co-Therapy Considerations
One of the most important aspects to consider in doing this type of group work is the value of a co-therapy model because it is virtually impossible to give each individual undivided attention. In a group situation it is very difficult to observe or record all of the underlying group dynamics going on with the result that some important information can be missed. Some adolescents may be more needy and end up vying for attention if there is insufficient attention to go around.
Doing co-therapy means that there are two people who are attending to the ebb and flow of the group and there is less chance of slipping into the role of disciplinarian if there are too many distractions. Also important is that there is an opportunity to mentor a harmonious relationship based on trust and respect to individuals who may be dealing with tension and strife in their own family or peer interactions. Discussing what went well, what was most significant, what did not work and ways to improve the overall flow and presentation of the group process can be extremely helpful (Liebmann, 2004).
271
There are also potentially harmful affects of a co-therapy model if the facilitators do not have a similar philosophical understanding of group work and similar goals and objectives for the group. Compatibility between the individuals running the group is essential. Knowing the respective roles and being clear on responsibilities prevents running into unexpected roadblocks. If discussion around the vision for the group is talked about and understood co-facilitating can be a wonderful opportunity to mentor good working relationships between people.
While the topics addressed in this section are touched on elsewhere in this project, this section was helpful in highlighting many of the important criteria for facilitating this kind of group. Although the list may seem daunting it is the responsibility of the facilitator to consider all of these and then choose the most important, realistic objectives and goals. These criteria are put forward so that the facilitator can examine their skill set and develop a style of interacting that incorporates these elements.
272
APPENDIX C
Methods and Procedures
Initial Intake Interview
An intake interview should be conducted using motivational and narrative techniques to establish the expectations the individual (and the facilitator) have of the group process and what they would like to accomplish. Also important, is to ask the individual if they would like their primary care physician included in the therapeutic loop because their doctor ultimately coordinates treatment, manages medical complications and determines whether a patient requires hospitalization.
It may be helpful to use a self-administered questionnaire such as the Motivational
Stages of Change for Adolescents Recovering from an Eating Disorder (MSCARED,
Prochaska, DiClemente, Norcross, 1992) utilizing Motivational (Miller & Rollnick,
1991) and Narrative (Madigan & Grieves, 1997; White & Epston, 1990;) elements to find out how motivated and where in the cycle the individual believes they are in being willing to change.
The MSCARED can pinpoint where an individual might be in a precontemplation, contemplation, action or maintenance cycle. From a research perspective the administration of the MSCARED over time also holds the promise of providing meaningful research data on “… how and when change happens, how long it takes to move from one stage of readiness to the next, and how often youth recycle through the stages before achieving more permanent change.” (Gusella et al., 2003).
To assess the eating disorder symptomatology, perceived body image, discrepancy between perceived body size and actual body size, and a measure of body distortion the
273
Page 2/Intake interview/dissatisfaction …
(Perceived Body Image Scale (PBIS, Manley & LePage, 1988), the Children’s
Depression Inventory (CDI, Kovacs, 1981), and the Eating Disorder Inventory-2 (EDI-2,
Garner, 1991) can also be used.
Clinical interviews are generally considered the gold standard in the assessment of eating disorders (Wilson, 1993), however, self-report measures on change can provide some reliability, concurrent and predictive validity (Gusella et al., 2003; Sysko, Walsh, &
Fairburn, 2005). Some research has found that self-report generates higher scores in assessing more complex features such as binge eating and concerns about shape, weight and dietary restraint (Black & Wilson, 1996; Fairburn & Beglin, 1994; Kalarchian,
Wilson, Brolin & Bradley, 2000).
Initial information has implications for changing ideal body image towards a healthier ideal and can be a predictor of readiness to change. The intake process may also identify those who feel the most hopeful or motivated to change, and those who might benefit most from the group process (Gusella et al., 2003). In a future research study using pre- and post questionnaire information the MSCARED, PBIS, CDI and EDI-2 could prove insightful on measuring whether this particular group process was helpful in motivating change, changing perceptions of body size, and/or changing attitudes.
Although there is debate about the usefulness of both formal and informal measures, it is my belief that these questionnaires can provide insight on where the individual might be in the change cycle, level of relative satisfaction with weight and body shape, and group treatment outcomes (Gusella et al., 2003). In allowing the individual to
274
Page 3/Intake interview/contemplate … contemplate the implications of being part of the group, both the adolescent and the interviewer get to rate readiness for change which offers an opportunity to discuss how close or far apart the client and the counsellor may be in their expectations of the process and outcomes. For the facilitator, it may provide information on what to expect in the individual’s level of functional ability to participate in the group process, predict their level of ability to think critically about their own growth, and the degree to which they will be able to creatively participate in the experiential process. Using this information can help the facilitator to tailor the activities to more closely meet the needs of the individual.
275
APPENDIX D
Methods and Procedures
Group Satisfaction Evaluation Form
The evaluation process is necessary to find out whether the program has accomplished its goals and objectives from an individual, group, counsellor, administrative, critical, creative, spiritual and therapeutic standpoint. Evaluating the program format and the benefits of the creative projects is necessary to discover whether the creative elements and the group discussion components compliment and integrate well with each other. The skills, knowledge and abilities of the group facilitator also need to be assessed from an individual and group counseling perspective to find out how successful the facilitator is in building rapport between members, facilitating group discussion and integrating the creative and critical components into the process. The program also needs to be evaluated from a philosophical perspective to determine how well the program fits the multi- dimensional and holistic model for therapeutic action (Gibson & Mitchell, 2002).
A short self-administered evaluation form should be completed at the final session to assess various dimensions of participants’ satisfaction with the group experience using a
Likert rating scale (1 = very dissatisfied to 5 = very satisfied). The evaluation would rate the level of satisfaction related to several specific domains and topic areas, contain open- ended questions regarding what they liked (did not like) about the group/format, what they might like changed (more/less time for discussion, more/less time for creative pursuits, more/less time for instruction, and more or less information). The evaluation process should also include a list of topics the individual might like to see covered in future workshops, a rating of the effectiveness of the presenter’s performance, whether
276
Page 2/Group Satisfaction/their issues …
their issues, fears and concerns were addressed well in this format, and an area for additional comments (Gibson & Mitchell, 2002).
The process should be documented from the perspective of the clinical counsellor with input from the co-therapist using an observational checklist noting the individual level of participation, and the use of individual creative journals and scrapbooks. Perhaps sitting down with each individual after the initial settling in period to discuss their autobiographical process and self-expression work would help to find out if the process is working for them. Also whether there are any issues they would like to address or any adjustments that they feel need to be made (Gibson & Mitchell, 2002).
Also important is to give individuals the opportunity to express concerns that may not be suitable for discussion within group sessions pertaining to group functioning, conflicts within the group or between individuals. Sometimes it is helpful to use a sociometric questionnaire to find out the group dynamics of who is popular, reticent, sincere, funny, good-natured etc. A good way to find this out is choosing characters for acting out roles in a play and assigning the best person in the group for that role.
The information is helpful in revealing how each individual views themselves and how they function inside the group. Also whether an individual’s perception changes over time. The tangible art pieces should also be looked at to see if they reflect a progression in self-discovery, experimentation, and artistic creation. The art history pieces should be evaluated for creative content, relevance, cohesiveness and whether they fulfill the criteria for the creative component (Gibson & Mitchell, 2002). Following is a series of evaluation forms that may be helpful for this purpose.
277
Intake Information Form
Client name: Date:
Referral source:
Presenting Problem(s):
Client Information:
Counseling Goal(s):
Next Session: Referral to:
Review confidentiality, limits of confidentiality and sign confirmation of informed consent: Date:
Any additional information:
278
Intake Information Questionnaire (Adolescent)
Part One: Contact Information:
Name:______Date of Birth:______
Evening Telephone #:______Daytime Telephone #:______
Emergency Contact Name and Telephone #:______
Primary Caregiver Name and Telephone #:______
At which number can I leave a confidential voice message for you? Day/Evening?
How did you learn about this service (Referral Source):______
Email:______
What expectations (if any) do you have for this process?______
Part Two: Previous Experience
Have you participated in any kind of therapy, coaching or counseling before (verbal, art etc)? Yes No Which type?
Did you find it a valuable experience? Yes No
Was anything left unresolved or incomplete? Yes No
Are you currently working with a therapist/doctor? Yes No
If so, have you advised them about this therapy? Yes No
If I am concerned for your safety, may I contact this person? Yes No
Part Three: Strengths and Vulnerabilities:
279
Page 2/Intake Questionnaire ….
Are you aware of your strengths when faced with challenges? Yes No
Can you name some of them?______
Do you know how to calm yourself?______
Do you have a sense of being supported in life? Yes No
Describe your support system:______
Are there any particular emotions that you struggle with from time to time? Please explain?
Are you currently taking medication, for example anti-depressants, anxiety medication? Yes No
How long have you been taking them?______
Physician/Psychiatrist’s name:______
Suicide Risk? High Medium Low None
Is there anything else you would like me to know about you?______
280
Page 3/Intake questionnaire/Limits of …
Limits of Confidentiality:
If I threaten bodily harm to myself or others
If there is any indication of neglect or physical or sexual abuse;
If subpoenaed by the courts, counsellors are bound by the law to disclose information
obtained during the course of art therapy and/or counseling.
Printed name: ______
Signature of Agreement: ______
Date: ______
281
Individual Session Notes
Client Name:______Date:______Session #___
Previous Session (homework, learning, goals, successes, failures etc)______
Session
Theme:______
Session
Tools:______
Session
Art:______
Client goals/Short Range/Long
Range______
______
______
______
Therapist
Plans/Observations:______
Changes required?______
282
Group Session Notes
Program time: ______Date:______No:___
Goal:
Objectives: 1.
2.
3.
4.
Group Dynamics:
Interventions: 1.
2.
3.
Tools:
Observations:
Recommendations:
McKenna/2005
283
TOPIC EVALUATION FORM 1 = Lowest Rating 10 = Highest Rating Rate the Workshop Topic Handout Creative Comment # # # Spiritual Topics Stages of Change Thinking Traps Defense Mechanisms Ego States Self-Esteem Power and Control Media Skill Building Therapies Medications Relationships Motivational Topics Critical Thinking Assertiveness Honouring … Quotations Quizzes Lanterns Masks Instruments Mobiles Mandalas Role Plays Videos
McKenna/Evaluation/2005
284
Program Evaluation
Name of Workshop:______Date:______
Instructor(s):______Location:______
1. Please list two or three aspects of the workshop you found most valuable.
2. Please list ways that the workshops could be improved.
3. Please list any topics that you think should be covered in future workshops.
4. How likely would you be to change or redirect your life as a result of these Poor Excellent workshops? 1 2 3 4 5 6 7 8 9 10
5. How well did the workshops meet their objective? 1 2 3 4 5 6 7 8 9 10
6. Please rate the overall effectiveness of the presenter’s performance? 1 2 3 4 5 6 7 8 9 10
7. Please rate the overall effectiveness of this workshop 1 2 3 4 5 6 7 8 9 10
8. Additional comments:
McKenna 2005
285
Evaluation Form - Facilitator
Please use the following scale: 1 = Lowest Rating 5 = Highest Rating
Rate Skills in teaching
Degree of preparation
Effective communication
Relevance of the course for you
Effective Communication
Relevance to Eating Disorders
Relevance of AudioVisual Examples
Encouraging Participation
Quality of Handouts
Rating of Lecturer
Any other comments
McKenna/Evaluation/2005
286
APPENDIX E
Guide - List of Session Themes andTopics
This Appendix provides a full list of session topics that cover ten spiritual themes identified in the literature reviews discussed in Chapter V on Spirituality, and Chapter VI on Eating Disorders. The topics span a total timeframe of approximately one year with each topic requiring between three and four weeks of group process. The format and structure of each session from week to week stays consistent except in the weeks when a group out trip, a performance, or visitor is planned. Introduction to the group program including discussion of the group philosophy, mandate, purpose, goals, format and structure of the group process would be discussed in the intake interview and also the first group session.
287
List of Session Themes and Topics
1. WHAT IS SPIRITUALITY?
How tragedies that occur in our lives are spiritual journeys that can be looked at as sources of strength.
Topic – Spirituality (3 to 4 weeks)
Opening Ritual – Quaich and expressing a hope (see Appendix M)
Critical Component: Honouring your spirit. What is spirituality/spiritual malaise? How can developing “spirit” support us? Use the honouring worksheets on spirituality and creativity (Appendix I). Learning to acknowledge our millions of seeds of potentiality.
How does that help with an eating disorder? Create a one or two page handout on the role of creativity in mind/body medicine. Introduce the idea of a quale (as discussed by Otto,
1957). Reiterate the purpose of using a quaich. Foster the idea of keeping a creative journal.
Week #2 – Use Mother Theresa quote on spiritual malaise. Learn to create the life you want to live checklist. Use healing words.
Week #3 – What is psychotherapy, types of psychotherapy, what is a personality disorder? Role play several therapeutic modalities. Concentrate on the benefits and strengths that can come from this knowledge.
Week #4 – Examine the Stages of Change using psychoeducational charts and handouts.
Get individuals to examine where they might be in the process of change and the impact of relapse.
Week #5 – Out-trip to the Vancouver shoreline as a group to float the finished lanterns.
288
Page 2/Session topics/Creative component …
Creative Component: One day my soul just opened up. Lanterns. Use the lantern project to honour themselves, to honour someone significant in their lives (living or dead), or to say something about the eating disorder. Discussion of the therapeutic value of creative work and symbolic action. Create a box lantern.
Art History Component: The History of lanterns from diverse cultures and how that relates to lives in the here and now. Connecting the past, present and future. Goldsworthy
Hand to earth. Nash Forms into time. Useless Fragile ecologies (Appendix S).
Closing Ritual – Quaich and expressing a worry (see Appendix M)
2. WHO AM I? – THE CLAY FROM WHICH I MOULD MY OWN IMAGE
Definitions of “self” incorporating discussions around self care, honouring our “being”.
Creative Project will span two or three weeks.
Topic – Self (3 to 4 weeks)
Critical Component: What is Self? What is our Wise Self? How do we celebrate our uniqueness, process, creativity and feelings? How do we honour ourselves? Use the honouring self worksheet. How does that help with an eating disorder?
Week #1 – Models for understanding eating disorders.
Week #2 – Expressing your needs and desires. Pros and cons resource list and codes.
Week #3 – Symptoms, debunking myths on dieting. Using survivor stories.
Week #4 – Quotes on eating disorders
Creative Component: Masks: An epilogue. Masks using clay, plaster, or paper mache.
Depict public/private, internal/external, authentic/inauthentic, perfect/imperfect selves
289
Page 3/Session Topics/related to … related to the eating disorder. Discussion on the therapeutic value of creating masks and the symbolic acting out with masks.
Art History Component: Use a handout on the history of masks from diverse cultures.
Discuss the importance of the role masks play in various cultures and for individuals psychologically. Incorporate Sonfist’s History and the landscape (Appendix S).
3. THE ROLE OF GOOD AND BAD RELIGION - EAST MEETS WEST
Belief systems, the role of religion and faith in people’s lives, existential beliefs, the God within. Consider Christian, Jewish, Buddhist, Hindu, Agnostic, Atheist perspectives.
Creative project will span three or four weeks.
Topic – Beliefs and Values (3 to 4 weeks)
Critical Component: What are beliefs and values? How do you distinguish between good and bad beliefs and values? How does an eating disorder compare to a religion?
How do beliefs and values affect Eating Disorders? Consider other cultures’ beliefs and values. Use the honouring worksheets to discuss beliefs and values. Discuss the idea of faith as a foundation of a belief system that works on oneself to expand knowledge.
Discuss the egosyntonic nature of eating disorders through the use of psychoeducational worksheets based on good and bad religions. Provide handouts on coping styles, similarities and differences between good and bad religions. Examine behavioural chaining to find out patterns of behaviour, triggers, avoidance tactics. Examine thinking traps using role plays, and reasoning error worksheets.
Week #1 – Relationship between eating disorders and bad religions.
Week #2 – Defense mechanisms and coping styles
290
Page 4/Session Topics/Week #3 …
Week #3 – Thinking traps and role plays, reasoning errors and behavioural chaining.
Week #4 – Examine personal ego states and those of family members.
Creative Component: A dedication to the ego. Create a life/medicine wheel using an
Ojibwe Pimiwitiisin wheel as an example (Appendix P). Create a drawing, painting or sculpture from world religions or world legends. Apply symbolism to create your own shield. Use core symbols based on the circle to analyze strengths, weaknesses and desires. Consider the universe based on the seasons.
Art History Component: History of life/medicine wheels from different cultures
(Appendix P). Discuss the therapeutic value of this process.
4. THE VALUE OF TRUTH
How to live your life truthfully, authentically, creatively, steadfastly.
Topic – The value of truth (3 to 4 weeks)
Critical Component: How do you live your life authentically? What does the research say about the connection to eating disorders? Use the honouring worksheets to understand authenticity and being genuine based on truth. Understanding how the truth can set you free. How does that knowledge help with an eating disorder? Use simple handouts to examine and discuss what it means to have a personality disorder, an obsessive compulsive disorder, the things to look for in depression. Discuss co-morbidity, substance use (abuse) factors from the research. Given that many of these individuals may be on some type of drug, discuss the types of drugs that may be used and the benefits and limitations of pharmacotherapies. Particularly go over the role of anti- depressants, anti-anxiety, and anti-psychotic medications affects on the body.
291
Page 5/Session Topics/Week #1 …
Week #1 – Understanding other personality disorders
Week #2 – Understanding obsessive compulsive disorders
Week #3 – Understanding depression
Week #4 – Understanding pharmacotherapies – anti-depressants, anti-anxiety, anti- psychotics.
Creative Component: The lie I do not tell. Nothing but the truth. Making a didgeridoo or a drum. An appeal to the senses. Bring in a didgeridoo player or drummer. Play a didgeridoo on individuals’ bodies. Start with feeling the vibrations and pulse on the hands. Gravitate to the head, chest and then the whole body. Decorate the didgeridoos to the sound of a didgeridoo or play a drum or finger piano while individuals work. Find the beat. Invite a didgeridoo player back to help them to play the didgeridoo. Discuss the health promoting properties of sound, rhythm and music. Relate this to the rhythm of life.
Art History Component: The aboriginal art history of didgeridoos or drums. Gilbert and
George The singing sculpture. Nemiroff, Houle and townsend-Gault Land, spirit, power
(Appendix S).
5. HOW TO CREATE PEARLS FROM THE IRRITATING SAND OF LIFE
Examine the value of resiliency from Christian, Jewish, Buddhist, Hindu, faith cultures.
Compare similarities and differences.
Topic – Resiliency (3 to 4 weeks)
Critical Component: How to build resiliency and honour awareness that recognizes and harnesses the spirit so that you can feed your soul and conserve your time, energy and
292
Page 6/Session Topics/resources … resources. Honour patience, steadfastness and stability and cultivate a healthy mental attitude. Honour balance. Honouring the act of surrendering as a spiritual principle and learning to practice being still in the midst of confusion. Learning to be present. How does that help with an eating disorder? Use worksheets to set SMART goals (specific, measurable, achievable, rewarding and time constrained). Use worksheets and roleplays to understand what it means to be empathic and to respond empathically. Learn how to practice these skills within the group by responding to someone in specific ways. Use worksheets to differentiate different types of helping, how to ask for help, how to create an ecomap and social support network. Discuss divorce facts and myths. Explore the value of good sleep management.
Week #1 – How to set goals. using a worksheet and understanding roadblocks
Week #2 – Understanding empathy and responding with empathy.
Week #3 – Asking for help, divorce myths, the value of sleep management
Week #4 – Visit a labyrinth (see Appendix O).
Creative Component: Create mandalas, sand sculptures and creative sand paintings.
Art History Component: Discuss the history of mandalas that have been handed down from the Paleolithic era. Discuss the purpose and value of sand sculptures from different cultures. Discuss the history and meaning of a labyrinth. McMaster Reservation. The power of place in aboriginal contemporary art (Appendix S). Body manipulation States of Being (Appendix S).
293
Page 7/Session topics/Opening …
6. OPENING UP TO SORROW
Dealing with death and dying, disappointment and despair, anger and resentment, guilt and shame, acceptance and surrender, loneliness, feeling underappreciated, being unfulfilled. Finding connections in loss, resting with uncertainty, accepting fear, tending to relationship with aloneness, believing that there is always something that can be sustaining. Learning to work and play. Use handouts and discuss the destructive nature of malicious thoughts and trying to be perfect.
Topic – Fear, Guilt, Doubt, Acceptance, Surrendering (3 to 4 weeks)
Critical Component: Honouring acceptance as a sign of courage. Honour fear by learning to embrace it, love it, deactivate it. Understanding how doubt creates the very thing we fear. Honouring guilt as a toxic emotion that leads to blame and a victim mentality. Honouring feelings and learning to acknowledge and embrace them whatever they may be. How does this help with an eating disorder?
Week #1 – Malicious thoughts
Week #2 – Grading oneself (story of survival)
Week #3 – How could I do anything different (story of survival)
Week #4 – Changes of struggles (story of survival)
Creative Component: On my own. Step by step. Read Struggling through. Read the poem Ozymandias. Sculpture or installation on the meaning of death and dying. Create a life or death journal. Create a feeling mobile or sculpture. Create a museum of loss on paper or with clay. Work through a eulogy activity.
294
Page 8/Session Topics/Art History …
Art History Component: How different cultures deal with death and dying through the art process. How different cultures honour the dead. What does death mean in different religions and cultures.
7. A PEACEFUL HEART
Meditation, discipline of the mind, body, spirit and being. The role of silence and humility in our lives. Patience, peacefulness, simplicity, conservation. Listening without having an agenda.
Topic – Honouring a peaceful heart, the value of honouring the mind, body and spirit with meditation, yoga, silence (3 to 4 weeks)
Critical Component: Honouring workshop sheets on peacefulness and understanding that if you want peace you need to be peaceful. Honouring meditation or yoga by taking a little time out of each day to still the mind and body. Understanding the therapeutic value of honouring simplicity by making our lives less complicated. Honouring the discipline to use our gifts and talents wisely. Learn focused attention with care. How does that help with an eating disorder? Discuss the role of the media and how to develop critical consciousness around advertising and fashion media. Use various media worksheets to develop personal awareness.
Week #1 – What is media literacy? Media activities. Tools for deconstructing media images and checklist.
Week #2 – Media quiz, questions, ad reviews
Week #3 – Political activism, portrayal of women in the media, facts on the media
Week #4 – Female role models, name your role model, honour a role model
295
Page 9/Session topics/Creative component …
Creative Component: Create a sculpture on “What stops the silence in a room?”
Deconstruct an old home appliance or discarded object and create a sculpture. This process helps to show how constructs can be taken apart, examined and deconstructed in different ways.
Art History Component: Study art history/art criticism/art philosophy on – What is beauty? Videos on Killing us softy, Beyond killing us softly, Merchants of cool.
8. FREEDOM OF CHOICE
The benefits and responsibility of making choices. How to manage personal boundaries
(both open and closed). Strategies for saying “NO!”. Honouring disappointment when we do not measure up.
Topic – Honouring responsibility and choices (3 to 4 weeks)
Critical Component: Honouring workshop sheets on recognizing choices and thinking of alternatives that honour greater growth in mind, body and spirit. Honour boundaries by knowing where they are and setting down clear limits. Learning to use personal power and understanding the power that others may have over you. How does this help with an eating disorder? Learn to understand coping styles and anger management skills.
Week #1 – Looking at power and control issues.
Week #2 – Understanding ego states, self, self-esteem, self-concept, self-awareness.
Week #3 – Effective communication skills. Identifying coping strategies. Fundamentals of assertiveness training.
Week #4 – Understanding anger styles
296
Page 10/Session Topics/Creative component …
Creative Component: The trial of Anna Rexopoulos and Billy Mia. Create an ancient
Greek trial with the group participants playing Judge (Hippocrates), Prosecution (Athena and the Athenians), Defence (Helen and the Trojans), jury. Have participants double as a father/mother/sister/friend. Special witnesses Zeus (with drum and lightening bolts), Thor
(expert witness for the prosecution), and an Olympic coach (gold at all costs) played by adult staff. The accused is a life sized doll who is accused with grevious bodily harm causing death. The Jury (made up of the girls) get to choose the sentence from – death in the lions’ den, banishment, probation or not guilty. Using a dramatic enactment is particularly helpful for individuals to understand the problem from different perspectives.
The get to try on different roles and be that person. They have to work through arguments and competing arguments and make judgements on many different levels.
They are encouraged to think of themselves as Greek philosopher queens - bright, cultured and gifted who are valued for their strength of character and ability to use sound judgement.
Art History Component: History of drama. The health promotional properties of storytelling, narrative. Different types of theatre from around the world. Use direct casting on Shedding life. Cragg’s A quiet revolution. Wallace’s Clayoquot protest. The
Art Guys performance Think twice (from Appendix S).
9. LEARNING TO FORGIVE
Forgiveness, compassion, acceptance of human frailties (especially one’s own). Learning to be non-judgemental (particularly with oneself).
Topic – Forgiveness (3 to 4weeks)
297
Page 11/Session Topics/Critical Component …
Critical Component: Honouring workshop sheets on affirmation and learning to forgive ourselves and others. Honouring compassion. Letting go of anger and resentment.
Learning to deal with feeling underappreciated or unappreciated. Honouring the past and coming to terms with it. Learning to understand, honour and worship our uniqueness.
Learning to articulate unique gifts and talents. Learn to write yourself a love letter. How does this help with an eating disorder? Foster the health promoting properties of keeping a creative journal. Discuss Anne Frank and how she used her journal. Learn the value of affirmation to oneself and others. Practice affirmations in the group.
Week #1 – Motivational writing. Using a creative journal
Week #2 – Everybody is a somebody, the courage to be myself.
Week #3 – The elephant in the room
Week #4 – Affirmations to self and others
Creative Component: Create boxes to articulate secrets, symbols, synthesis and safety.
Create an art piece that makes a public statement.
Art History Component: Discuss art as social change/art as political statement such as public murals, cartoons and graffiti on political and social issues. Kubota The exploration of possibility (Appendix S).
10. TENETS FOR LIVING A “GOOD LIFE”
Faith in the goodness of others, love your neighbour as yourself. Ordering your life.
Purpose, service, willingness, expansion, wisdom, kindness. Gratitude and being thankful, counting your blessings, honouring life, being joyful, trust attending to the
298
Page 12/Session Topics/present by … present by using the power tools of humour, hope and love. Optimism versus pessimism.
Practice affirmations.
Topic – Cultivating the Optimistic Life (3 to 4 weeks)
Critical Component: Honouring workshop sheets on gratitude and joy. Learning to be grateful and joyful. Learn to fall in love with living the optimistic life and living life to the fullest.. Honour delight and wellbeing. Learn joy in thought, motion and action. Learn about the health promoting properties of unselfish giving. The therapeutic benefits for the person who gives. Learn strategies for practicing random acts of kindness. How does this help with an eating disorder?
Week #1 – Create the life you want to live
Week #2 – Healing thoughts, words and actions
Week #3 – Life is a test …, it is only a test
Week #4 – Spontaneous creative art play
Creative Component: Discuss through the art that heaven’s here on earth. A miracle for two. Create kites or large sculptural dream catchers that depict hopes and dreams. Create a communal sand sculpture or mural.
Art History Component: Use the book The Kite Runner. History of kites and dream catchers. Videos on themes such as birth, rebirth, myth. Art film Night Cries. Lung
Stones and flies. Lutz Perceptions nature (Appendix S).
299
APPENDIX F
Suggested Sample Sessions
The five sample sessions suggested here are provided to give a facilitator an idea of how to integrate the various components together within a session. It also helps to understand how the various art therapy components are integrated from week to week.
The first session describes ways that the group program can be introduced to participants so that they have some sense of how the group program will unfold, the benefits of the group process, how this program can help, and the goals and objectives of incorporating these elements together in one group program.
Session one provides an overview of the program structure, the therapeutic benefits of groups and the rules governing group process. It also explains how the sessions will unfold, how the various components will be integrated, and the goals and objectives of integrating art therapy. In Sessions Two and Three the psychoeducational components concentrate on helping individuals understand spirituality. Session Three introduces psychotherapy and examines a few psychotherapeutic models. The purpose being to help participants understand differences in the goals and objectives between some of the therapeutic interventions that they may have come across in the past, or that may be used in the group program. Role plays between the facilitator and a participant could be enacted to demonstrate psychoanalytic, psychodynamic, cognitive/behavioural, feminist/relational, narrative and art therapy modalities in action. In Session Four participants are asked to examine Motivational Enhancement Therapy (Rollnick &
Miller), and the Stages of Change model (Proschaska, Norcross & DiClemente) to help participants determine where they think they are in the change cycle and understand how
300
to move through the cycle of change (see Figure 1). The Fifth Session describes the out trip to symbolically release the lanterns that have been created in the art therapy component of the workshops in sessions two through four.
301
Session 1
Purpose:
The general purpose is to give an overview of the format and structure of the workshops to set the groundwork for future weeks. Start developing the foundation for working alliances and begin to connect and build cohesiveness to enable participants to unify towards some end in an informed way starting with more general and impersonal issues and working towards more concrete and personal concerns. Topics that are more general and require less self-disclosure would come first and greater group support and cohesiveness would develop over time.
10 Minutes - Short Introduction and overview of the spiritual, critical and creative elements of the program using a story board, a large newsprint pad, or powerpoint presentation. Discuss briefly the issues and themes that will be covered in the coming weeks and the healing potential of these types of workshops. Discuss the parameters of how the group will interact, guidelines for confidentiality and ethical considerations, benefits of the group process, and rules around clean up. Ask them to consider adding topics as the group moves forward. (Use either the handout Meaning of spirituality, or Understanding spirituality.) Answer any questions that come up;
5 Minutes - Opening ritual – . Explain the value of symbolism in our lives Explain the opening ritual that will start the group process each week and give them a brief introduction to why this ritual might be helpful. Briefly explain the purpose and use of the Scottish quaich (see Appendix M). Start with yourself (therapist) so that they can see what is expected and encourage each individual to take a stone and express a hope in one
302
2/Session One/or two words … or two words. An example would be (kindness, strength, peace etc.). Meditative music in the background to set the mood is optional. Explain that the ritual process might feel slightly awkward at first but that the power of it will grow each week. Throughout the session the individual keeps the stone near them. The facilitator could encourage the girls by expressing their own worry out loud although it should be made clear that this verbal expression out loud is not necessary and that level of participation is strictly the choice of each individual.
10-15 Minutes - Split into groups of two and ask each pair to interview each other about a grandparent. (Usually it is easier for adolescents to talk about someone else of significance in their lives). Have each person introduce the person in a two minute introduction;
10 Minutes – Hand out an introduction explaining very briefly what will be involved and how it relates to the overall plan. Hand out a psychoeducational folder containing condensed, one page informational, spiritual, creative, critical thinking and motivational components. Give each person a creative journal with the idea of encouraging each participant to record their own process. Stipulate that it is for their own use and they are not expected to show or discuss it with anyone in the group or with the facilitators unless they would like to do so. Answer any questions that come up;
5 Minutes – Overview of the creative process. Encourage an open studio atmosphere;
Participants are encouraged to name, date and document their weekly creative experience with a digital camera and start to build an art portfolio for a retrospective look back in future weeks.
303
Page 3/Session One/10 Minutes …
10 Minutes – To make the transition to the creative portion of the session use an art video to introduce an artist or art process, or take an ordinary object in the room such as a chair, turn it on its edge and ask the group “What do you see?”. Use this to discuss positive/negative space, aesthetic value, utilitarian function, shape, colour, texture etc. Is it art? Why or why not? Is it beautiful? Does it have aesthetic value? Why or why not?
20 Minutes – Choose a fun non-threatening art project using a range of media
(pencils, crayons, oil pastels, paints) to get an idea of what individuals would freely choose to use. Collage can be a pleasant activity without too much pressure.
10 Minutes – Clean up and debrief about the creative process making sure to include everyone – open up issues to the group for general comment, questions or discussion.
What are you thinking? What are you feeling?
5 Minutes - Closing ritual – Repeat the Quaich ritual but this time each individual puts the stone back in the cup to symbolically get rid of a worry (e.g. fear, anxiety, stress). Encourage them to express this out loud if they can.
304
4/Session 2…
Session 2
Purpose:
Provide information on spirituality. Encourage simple steps towards mindful practice.
Introduce information as food for thought in a gentle, non-threatening atmosphere. Page
Continue to stimulate conversation between group members. Continue to build rapport
confidence and safety.
Psychoeducational topic for this session: “Spirituality”.
5 Minutes - Opening ritual – Quaich – Pick a stone/express a hope
10 Minutes - Short Introduction of spirituality either with a handout or in a short
powerpoint presentation (Spiritual Session Handout). Use a large newsprint pad to make
the “mind/body/spirit” connection. (Emphasize that these workshops are not about
replacing anyone’s personal religion.) Use a few salient points from the literature review
to make up a handout. I like Starratt’s concept of the mind-body-spirit connection and
Otto’s idea of the quale to emphasize that it is something we all have and that it can be
practiced. Emphasize the benefits and strengths that can come out of this way of being.
5 Minutes – Take one or two provocative quotes and have someone in the group
read it out. For example:
“Mother Teresa, responding to a question about her impressions of the United
States said that we are poorer here than even the “poorest of the poor in the slums of
Calcutta.” She said that North Americans are spiritually poor, worse by far than the
worst material poverty.” (Newmark, 2004);
305
Page 5/Session Two/A Tibetan …
“A Tibetan lama escaped Tibet by walking to India over the Himalayan mountains in snow and ice, wearing peasant clothing to avoid being noticed by the occupying Chinese forces. He witnessed his countrymen and fellow monks being humiliated, tortured, and killed. He lost his home, monastery, and his culture. Living in a refugee camp in Northern India, he saw thousands more Tibetan exiles die from
Tuberculosis and other infectious diseases. However on his first teaching trip to the
West when he was driven around Europe, tears ran down his cheeks. Why? Because of the suffering he perceived in the hearts and minds of Europeans.” (Newmark,
2004);
“While visiting India, I was invited to join a family celebration of a feast day for Durga, a Hindu goddess. They draped a garland of marigolds around my neck, daubed a crimson caste mark between my eyebrows, and offered me the best of their food. Holiday foods are great treats in a place where every day each of two meals is
Dalbat (white rice with a tablespoon or two of lentils). Their eyes shone as they watched me enjoy their feast. I had never seen such simple, uncomplicated joy in adults. It was the first time I understood what Mother Teresa meant.” (Newmark,
2004;
“I started treating eating disorders in the late 1970’s … Very soon it seemed apparent that the suffering I saw in people who came to me was not really about their weight, their eating, or even their family history. I didn’t know what to call what I was seeing, so I named it “spiritual malaise”. It reminded me of the wasting deaths in babies who are fed but not held or cuddled. I saw it not just in people who were
306
Page 6/Session Two/under-eating … under-eating, but also in those who felt pressured to lose weight to conform to a conventional or ideal of beauty… My client, and indeed my culture, were starving.”
(Newmark, 2004);
“We can see evidence of this starvation everywhere, not just in our obsession with body image and food. Our food portions grow larger as our ideals of an acceptable body grow smaller. New drugs, both pharmaceutical and recreational, are created to give easy, instant results, even with the risk of serious negative side effects and powerful addiction.” (Newmark, 2004);
“Alcohol and cigarettes are marketed to young people for whom “partying” often means binge drinking until passing out. We buy storage bins, boxes, and rental space to hold stuff we don’t use. We drive ever-larger cars that use more and more gasoline and park them in three- or four-, or five-car garages. Our homes, cars, closets and garages can’t get big enough. We collect – dolls, coins, jewelry, shoes, make-up, cars, kitchen gadgets and knickknacks of all sorts – but never have enough.”
(Newmark, 2004);
“The media feeds us ever more stimulating fare – car chases, murders, loud music, special effects, people doing dangerous things out of greed, average people being made-over with plastic surgery and liposuction. We think nothing of people
risking their lives to have weight loss surgery because we all feel the stigma of fatness from the media, medicine, and the government.” (Newmark, 2004);
“We prowl the malls and internet looking for more things, more food, more action movies. We travel to exotic locales from Lahaina to Istanbul, yet spend much
307
Page 7/Session Two/of our time …
of our time there shopping in chain stores for t-shirts. Three quarters of the world’s
population stave while we celebrate the promise of the next diet pill. Our leaders and
the media often refer to us as “consumers” rather than “people”, or “citizens”, and we
consume the resources of the earth like insatiable termites as if there were no
tomorrow.” (Newmark, 2004).
5 Minutes – Use one or two of the questions below to stimulate conversation. Have the girls read a couple of questions to the group.
1. How do we nourish ourselves spiritually?
2. Is this insatiable hunger the result of the advertising industry that tells us a hundred times a day, directly and indirectly through images and suggestions, that we won’t be happy until we buy the next object or adventure, or until we lose some pounds?
3. Is advertising the spawn of our materialistic, post-industrial age where the bottom line is profit rather than quality of life.
4. Does the disintegration of our families result from migrating from place to place.
5. Is it the result of parents, siblings, cousins and grown children sitting behind
Gameboys, computers or TV screens instead of having face to face conversations with real people?
6. Does time pressure exacerbate this spiritual hunger as parents work long hours to put food on the table?
7. Are the “luckier” kids the ones whose parents struggle to buy bigger houses and cars or the ones shuttling their kids to and fro from soccer to ballet practice leaving ever less quality time?
308
Page 8/Session Two/Is it the …
8. Is it the implicit promise that we should feel happy all the time, and we are just a pill, potion, possession, diet pill from realizing that?
9. Has - “You can never be too thin or too rich” - become our unconscious driving force, replacing meaning, love and fulfillment as our goals in life?
“In the Buddhist tradition there is a concept called Duhkha, which in part means the ordinary suffering we endure when, driven by habit, we constantly look to the next moment for fulfillment, rather than enjoying things as they are now, in the present moment. We might notice it while we are eating a meal and thinking about the next one, or when we don’t taste the bite in our mouths because we are hurrying to take another.
We “can’t wait” to grow up, take our first drink, graduate, get a job, marry, buy a house, have children, get the kids raised, and retire.” (Newark, 2004);
“While wishing our kids would grow out of a difficult phase, we miss many of the precious, fleeting moments of their childhood. We hurry to our next destination, perhaps talking on the telephone as we drive, never noticing our surroundings as we whiz by. Or while vacationing we plan the next diversion or entertainment rather than savouring the one at hand. In short, in our endless craving for more, we seldom truly partake of, or savour, the experience of the moment.” (Newmark, 2004).
“Neuroscience tells us what religious traditions have known for millennia – that it takes deliberate, repetitive practice, doing something over and over again, to create Page different habits or patterns of behaviour, thinking, and feeling. Regardless of what the practice is – prayer, contemplation, meditation, sacred reading (lectio divina), being in nature, tai chi, yoga (to name a few) – taking quiet time each day in solitude enables us to
309
9/Session Two/stop identifying … stop identifying with the endless cravings of our culture and habits, to know instead our essence, the ground of our being, “the still small voice of the soul”, however one might name it.” (Newmark, 2004);
“We can begin to practice seeing our fellow creatures not as obstacles to compete with, good or bad depending on their body size, but as living beings who like ourselves wish to be happy and free of suffering, worthy of respect and consideration. We can begin to notice, appreciate, and find meaning in the little moments that are truly the only life we have. (Newmark, 2004)
“This very moment, we can look up from this page, take a breath, notice our bodies as they are right now, the surfaces that support us, the clothing and air that touch our skin, our thoughts and feelings as they come and go. We can notice our breath, feeding and nourishing us. We can say, “This is enough, this is good.” (p. 88-89). (Newmark, 2004).
5 Minutes - Have the group complete the Honouring Spirituality worksheet
(including facilitators). Play Five for Fighting’s song “You only have a hundred years to live.” in the background. Using their own popular music gets their attention because most of them expect to hear “therapeutic music” such as nature sounds etc. It brings their guard down and helps to alleviate the worry most of them have that somehow this process is going to be “religious”!
5 Minutes – Creative component – Lanterns.
Suggest that lanterns are used to celebrate life and death, and symbolic of the light that comes from enlightenment and knowledge. Use an art history piece or a few powerpoint slides with some pictures of festivals that are held all over the world in many different
310
Page 10/Session Two/cultures … cultures. The lanterns will take two to three sessions to make. Encourage them to take their time, enjoy the process, and document with the camera or journal their process. Ask them to consider using the creative process involved in lantern making to:
1. Honouring themselves (most of the girls will not be comfortable with doing this)
so provide the following other options;
2. Honour someone in their life who has died;
3. Acknowledge a loss in their life;
4. Make some creative statement about the eating disorder.
30-40 Minutes – First Lantern Session – Build the lantern frame (see handout).
This thirty or forty minute span is a good time to gently reinforce particular points, or to use motivational interviewing skills to start a dialogue. Sometime the conversation flows freely and other times they can enjoy the therapeutic benefits of the silences.
10 Minutes – Clean up and debrief about the creative process making sure to include everyone – open up issues to the group for general comment, questions or discussion.
What are/were you thinking? What are/were you feeling? Try to get some of them to discuss the theme they are working on although it might be a bit early in the process.
5 Minutes - Closing ritual – Quaich – Express (or think of) a worry. As the weeks progress the individuals should become much more comfortable with expressing their hopes and worries
311
Page 11/Session Three…
Session Three
Goal:
Continue to make the group more comfortable and continue building cohesiveness. Start to consider the therapeutic benefits of these workshops.
Psychoeducational topic for this session: “Introduction to Psychotherapies”.
5 Minutes - Opening ritual – Quaich – Pick a stone/express a hope
10-15 minutes - Short Introduction of psychotherapies using some of the psychoeducational handouts or a short powerpoint presentation. Use a large newsprint pad to make connections. Emphasize the benefits and strengths that can come out of this knowledge.
5 minutes – Role play therapist and client using psychoanalytic, psychodynamic, cognitive/behavioural and art therapy approaches. Usually there are a few individuals who are more keen to participate in the process than others. But the process benefits everyone because they are observing and listening.
5 Minutes - Have them complete the Honouring Spirituality worksheet. Everyone participates even the facilitators. Play some rap music while they fill in the spiritual worksheet. Each week individuals will become more comfortable with this honouring process, anxiety will drop and most of the adolescents will begin to become more comfortable.
30-40 Minutes – Second Lantern Session – Start to design and decorate.
Remember while they are working creatively they begin to relax and usually enjoy the process. Each week their defenses should begin to come down. Use the time to gently
312
Page 12/Session Three/zero in on … zero in on building trust and safety, connecting, and creating conversation. Look for the window of opportunity for “teaching moments”. Offer lots of encouragement without being patronizing or expecting them to achieve too much.
10 Minutes – Clean up and debrief about the creative process making sure to include everyone – open up issues to the group for general comment, questions or discussion.
What are/were you thinking? What are/were you feeling? By the second week some of them will begin to talk about what their design plans and themes are.
5 Minutes - Closing ritual – Quaich – Express a worry
313
Page 13/Session Four …
Session Four
Goal:
To connect, connect, connect. Continue to build group cohesiveness. Start to take note of individuals who may be struggling with the process more than others. Who is talkative?
Who sits back and says little? Who seems to be engaged in the psychoeducational or creative processes? Who may be feeling anxious? Who seems disconnected from the process. Who are the leaders in the group?
Psychoeducational topic for this session: “Stages of Change”.
5 Minutes - Opening ritual – Quaich – Pick a stone/express a hope
10-15 minutes - Short Introduction of Stages of Change using small psychoeducational handouts or powerpoint presentation. Emphasize the benefits and strengths that can come out of this knowledge.
5 minutes – Get them to examine and identify where they might be in the process of change. Stimulate conversation using motivational techniques about where they might be
(precontemplation, contemplation, action etc) and what it might take to move them forward. Particularly have them consider relapse and the impact of that. How they will deal with that if and when that happens.
5 Minutes - Complete the Honouring Change worksheet. Play some soothing music while they fill in the spiritual worksheet.
30-40 Minutes – Third Lantern Session – Complete the lanterns.
314
Page 14/Session Four/They are …
They are continuing to relax, their defenses should be dropping, and many of them will be showing some initiative with design, form, shape and colour. Use the time to gently zero in on building trust and safety, connecting, creating conversation. Look for that window of opportunity for “teaching moments”. Offer lots of encouragement without being patronizing. Make sure that the process and not the product is emphasized. Get them to start anticipating saying goodbye to their lantern. What will that feel like?
Releasing the lantern is a very communal and symbolic act so prepare them for the potential of feeling emotional.
10 Minutes – Clean up and debrief about the creative process making sure to include everyone – open up issues to the group for general comment, questions or discussion.
What are/were you thinking? What are/were you feeling? By the third week they know what to expect. If you have created the right open studio atmosphere that balances some structure with free creative expression you begin to see the confidence and cohesiveness build. Some of them will slowly begin to open up. If you get one or two to start this process the rest will follow their lead.
5 Minutes - Closing ritual – Quaich – Express a worry.
315
Page 15/Session Five …
Session Five
The fourth lantern session is an out trip with the group to the Vancouver shoreline where they float the lanterns or set them off on their journey. Usually I try to pick a part of the beach that is not too crowded yet not so secluded that they have to interact with their environment. The group comes together as a community and they observe each other’s final process. The opening and closing ritual is done in the open air. Each individual is asked if they would like to say a few words about their lantern although everyone’s right to privacy is respected.
As the facilitator, I create a lantern and talk about my own process which usually encourages some of the girls to do the same. I have found some of the adolescents like to put the lanterns in the water while others like to sit them at the waters edge and wait for the tide to carry them away. We talk about the symbolic act of getting rid of something and starting over, saying goodbye and moving on.
As a group, we talk about participating in a symbolic ritual that has been passed down over centuries and the different practices with lanterns that take place all over the world such as honouring the souls of ancestors and family members who have died. They are asked to celebrate life, contemplate the wonders of their environment and the universe, and be thankful. It is often a moving experience for everyone.
When I have used the lanterns in the past, some individuals honour a parent, grandparent or pet who has died. Some use it to get rid of, or to rail against, the eating disorder. Others who are in the earlier stages of change will use it to make a “pretty”
316
Page 16/Session Five/lantern … lantern. Having an example of the frame put together for them to observe because it takes the anxiety out of the task. Building the frame gives them a sense of accomplishment because they use cutters, wire snips and glue guns to make a sculptural three-D object. It has been my experience that initially this population has some anxiety around making 3D objects because it challenges them even more than paint and paper. However, once they begin to physically engage in building the lantern the anxiety dissipates and they have the added bonus of contemplating the 3D aspects of positive and negative space.
The personalization of the lantern, choosing colours, patterns and deciding on the design and what their theme will be creates order out of chaos and builds ego strength through the “pillow talk” with the ego. The creative process is health promoting by allowing the unconscious the opportunity to rise up, and as individuals and as a group, they begin to feel more confident, empowered and spirited because they have built something that is also aesthetically pleasing. They feel very successful because they feed off each other’s success and seeing a room full of lanterns being made is a very uplifting and spiritual experience!
Like Edith Kramer (2001), I believe that many of these young women will have been crafted to death because art education has been perverted somewhat in a search for novelty or a quick fix. Many of them may be feeling empty, bored or chronically dissatisfied. It is my belief that some of these girls’ may not have had many truly creative art experiences. These teenagers may have been exposed to an array of artistic techniques but only in a superficial way and may not know what it feels like to be truly engaged in creative acts. Therefore, it is important from time to time to reiterate the health promoting
317
Page 17/Session Five/properties … properties of experiencing the creative process and the therapeutic properties of the play space.
A distinction needs to be made between creative communication and stereotyped chaos. Kramer (2001) suggested that many of our children and adolescents have been
“bribed, seduced and left empty” and “…fed on substitutes until they have lost the capacity to respond to direct experiences.” (p. 9). Novelty and stimulus are good places to get these adolescents interested in art but the intent is to move them towards more adventurous work. The idea is to take their impoverished, distorted or atrophied faculty of observation and develop creative fantasy into imagination. The truly creative process takes work and rewards often come slowly. As Kramer (2001) suggested “…replacing superficial substitutes with substance, passive consumption with active participation [is likely to meet with some resistance]”(p. 11). However, I believe that art therapy can function well under all sorts of difficulties.
318
APPENDIX G
Building a Lantern
(Helpful tips for getting started)
This Appendix provides helpful tips for building a lantern (Topic 1, Sessions 2 - 5).
1. Assemble below the list of supplies you will need:
Framing Material:
Bamboo sticks (to save money buy in longer lengths and cut to size);
Bundles of 500 pieces in 4’ lengths can be purchased if you find an importer but
lengths can also be bought as most hardware or garden stores;
To cut Bamboo use rose clippers, tin snips or wire cutters.
Tissue:
Packages of bulk coloured tissue paper can be purchased at any art or craft store;
White tissue tends to disintegrate while drying so for white use rice paper instead;
Build from light colours to dark. If you start off too dark, the light and decorations
will not show up quite so well and more intense colours may run;
Use scraps for decorations.
Wrinkled tissue will tighten and stretch with application of glue solution.
Always use a soft bristle brush to apply the glue solution or you can tear the
tissue. (It is extremely fragile when wet.);
Tissues with a finished shiny side can be used but it repels glue solution initially.
Glue Solution:
White glue mixed with water. 2/3rds glue to 1/3rd water. (I prefer a thicker
solution the consistency of cream.);
319
Page 2/Appendix G/If glue dries …
If glue dries white instead of clear, the temperature of the glue is too cold. Mix
with warm water or if solution is already pre-mixed, rest the container with glue
solution in hot water until solution warms up.
Drying lanterns near a heat source for a time will also reduce the likelihood of
glue drying white.
Hot glue:
Several glue guns (preferably one for each person). (I prefer the small to medium
sized guns because they are more maneuverable and manageable.);
Low temperature craft glue sticks will not hold the lanterns together;
Have a First Aid Kit and a burn gel such as Aloe Vera handy;
Instruct individuals on working carefully and safely at the start of the session and
what they should do in the case of burn or accident.
Candles:
Minimum safety distance all the way around the tealight metal cup that will be
placed on the inside of the lantern is 2” inches.
The tin foil cups I use to hold the candle are the individual tart size that you buy
in one dozen or two dozen boxes in the supermarket;
Ensure that the area is well ventilates and never use tissue directly over the flame
of the candle;
A good minimum safety distance is 4” to 6” inches around the sides and 2.5 times
the height of the candle from the top of the flame to the roof of the lantern.
320
Page 3/Appendix G/Lanterns …
Lanterns:
Always attach hanging loops and install candles before adding tissue;
Prevent lanterns from touching while drying;
For fire safety, all tissue lanterns MUST be coated in a final coat of glue solution
(outside only);
Note: Some people mix Borax and water to use as an added fire retardant. Nine
ounces of Borax to one gallon of water. Put in a spray bottle and apply when glue is
dry (only when glue is dry).
***Borax renders the paper fire resistant – NOT fire proof***
321
Box Lantern
Preparations:
Cut 16 (sixteen) bamboo pieces 12” inches long.
Using a hot glue gun and the 6# bamboo pieces, build top and bottom squares. At
each corner place one edge on top of the other by overlapping the bamboo (see
Figure #1).
Attach loops Glue at to top cross cross sections for sections. hanging.
Figure #1 Figure #2
Hot glue (2) cross pieces so that they lie parallel to each other across the centre of
the BOTTOM SQUARE. The two pieces should be close enough together to hold
a small tin foil tart pan that will hold the tealight. The bottom of the tart pan will
be glued to these strips (see Figure #2).
Next, attach four pieces that will join the top and bottom squares together (they
are the upright pieces that will support the walls of the lantern. Glue the upright
pieces to the inside edge at the corners for greater frame stability. This forms the
box shape (see Figure #2).
322
Page 2/Appendix G/Box Lantern/Once the …
Once the frame is built, attach wire hoops for handling on all four corners. Ensure
that the wire is wrapped around all three joining pieces of bamboo that meet at
each corner (See Figure #2).
Hot glue the metal bottom of the tealight to the tart pan.
Hot glue the tart pan to the cross pieces on the bottom square of the lantern
(making sure to centre and secure it in the middle).
Cut the tissue to fit each side or use a length of tissue that can wrap around the
outside edges of the frame. Coat the uprights on the frame with glue solution and
apply the tissue. Anchor the edges and contact areas of the overlapping tissue with
glue solution. Either trim the tissue to fit or cut slightly oversized and fold under.
Do all four sides. Leave bottom and top open, and there is no need for a second
layer.
Using thin decorative wire (or fishing line), create a central hanging point for your
lanterns by attaching it to the corner loops. Use this central loop to hang and dry
the lantern.
Attach the central hanging loop to a bamboo stick either by typing on or using
duct tape for carrying.
323
APPENDIX H
Psychoeducational Resources
Full List of Psychoeducational Topics and Resources
Below is a list of recommended psychoeducational topics, resources and handouts that would be required for running this group. Including the whole manual is beyond the scope of this project but examples are included from this list in Appendices D through T.
For instance, it would be helpful to come up with a mandate for how the group will function such as the following:
This is our group. Its success or failure is up to us. We come together in search of ourselves. What we have to share is honesty; What we hope to gain is trust. Through expressing our feelings, hopes and dreams we can become known to one another. Friendship and self-understanding are the rewards.
We will honour ourselves by respecting the privacy of each member, and by keeping disclosures within the group.
What we see, what we say, what we hear – should stay here.
There are only two rules for this group: No side conversations allowed, and We must be kind to one another.
1. Groups:
Group statement
List of Session topics
Psychoeducational Group Purpose and goals
Description of open talk
Description of the psychoeducation group format
324
Page 2/Appendix H/Spirituality …
2. Spirituality
The resources included under spirituality include a simplified spiritual chart that gives visual representation to show the mind/body/spirit connection. A checklist of things individuals should do to create the life you want to live such as putting themselves on top of their list, practicing extreme self-care, building strong relationships with themselves and others, listening to their inner wisdom, learning to say “no” unless it is an absolute
“yes”, spending time and energy on what brings joy, practicing self-reflection, using a creative journal etc. This section should also contain one or two page handouts on the meaning of spirituality from the various concepts expressed in the literature review on spirituality, and a series of one page honouring exercise sheets based on the list suggested below (example shown in Appendix I). Also some question on spiritual hunger such as
What is it? How does it happen? What can you do to nourish it? What does a balanced life look like. What do you want more of and what do you want less of? The value of relationships, fun and adventure, and contributing to the welfare of others.
Spiritual health chart
Create the life you want to live checklist
Honouring exercise sheets on Acceptance, Affirmation, Anger, Authenticity,
Awareness, Balance, Boundaries, Choice, Closure, Compassion, Confusion,
Conservation, Creativity, Disappointment, Discipline, Devine, Doubt, Faith,
Fearfulness, Feelings, Forgiveness, Freedom, Fun, Helplessness, Hopelessness
Gratitude, Growth, Guilt, Joy, Loneliness, Meditation, Order, Patience,
325
Page 3/Appendix H/Peacefulness
Peacefulness, Prayer, Process, Self, Service, Simplicity, Surrendering, Trust,
Truth, Unappreciation, Unconditional Love, Yourself (examples in Appendix I).
Meaning of spirituality
Understanding spirituality
A List of questions to ask to stimulate conversation
Healing words
3. Eating Disorders
This section should provide a handout on a variety of models for understanding eating disorders including spiritual, biomedical, sociocultural, feminist, psychological perspectives. Also a handout on comparing eating disorders and good/bad religion. Also a worksheet on how to express needs and desires such as creating visual reminders, taking responsibility for yourself and the choices you make, being encouraged to take risks, accept and work with help and support, plan changes, develop relationships. It should also include worksheets on defining individual pros and cons, a pros and cons code list to identify friend or foe, health promotion or loss, feel good/bad, fitness/illness, specialness/attractiveness, power and control, love/hate, comfort/discomfort etc. As well as providing a worksheet of statistics that debunk diet myths, tips for taking a more healthful approach, and stimulating discussion with provocative quotes (see Sample
Sessions, Appendix F).
Models for understanding eating disorders
Similarities between eating disorders and good and bad religions
Expressing your needs and desires
326
Page 4/Appendix H/Pros and Cons …
Pros and Cons Resource worksheet
Pros and cons codes
Debunking diet myths
Symptoms, dieting, debunking myths
Is dieting really worth it
Quotes on eating disorders
Excerpts from “Reviving Ophelia”
4. Change
This section incorporates the motivation enhancement model of change, the stages of change and the motivational interviewing excerpts from Chapter III. These should be used to develop one page handouts for participants. Figures One and Two should be used to show a visual representation of the various stages of change. A change worksheet should be used to determine a plan, goals and objectives of change. Also a worksheet that considers when, what are the signals to look for, the good things and not so good things of changing. What might be the result of change? What has worked in the past? What else could help? Consider breaking down steps into even smaller more manageable pieces using SMART goals.
Motivational model for change
Stages of change (copy
Motivational Interviewing
Change plan worksheet
Changing behaviour for your health
327
Page 5?Appendix H/Psychological …
5. Psychological concepts and Terminology
This section should include handouts on concepts including a brief description of various personality disorders to help individuals understand the complex nature of an eating disorder and to demystify some of these illnesses.
What is psychotherapy?
Types of psychotherapy
What is a personality disorder?
6. Psychotherapies
This section should provide handouts on various types of psychotherapies such as psychoanalytic, psychodynamic, cognitive/behavioural, motivational, narrative, art therapy etc. Roleplays can be used as described in Sample Sections (Appendix F).
Worksheets on examining reasoning errors and patterns of behavioural chaining that may perpetuate an eating disorders, defense mechanisms and how they work, examining different coping styles. Also worksheets to examine thinking traps, ways to role play these, examining ego states of yourself and significant others so that individuals can understand differences in how people relate to each other and ways that can be used to interact more effectively including power and control issues.
Psychoanalytic approach
Psychodynamic approach
Cognitive/Behavioural approach
Feminist/Relational approach
Narrative approach
328
Page 6/Appendix H/Art Therapy …
Art Therapy/Experiential/Expressive approach
Understanding psychotherapies
Therapist client role play
Reasoning errors and behavioural chaining
Defense mechanisms and coping styles
Thinking traps and role plays
Ego states
Self, Self-Esteem. Self-concept, Self-awareness
Power and Control
7. Personality disorders
This section should include one page worksheets that explain briefly different personality disorders because they are often co-morbid conditions in eating disorders.
Other personality disorders
Obsessive compulsive behaviour
Depression
8. Pharmacotherapy
This section should have handouts on pharmacotherapy including how they work, and the risks and benefits of using drugs.
Antidepressants, anti-anxiety, anti-psychotics
9. Survivor Skills
This section should include life, leisure and social skill building components such as how to communicate effectively. Also included are coping strategies, personality types,
329
Page 7/Appendix H/fundamentals … fundamentals of being assertive and anger management strategies. Also how to set goals and avoid roadblocks, sleep management and divorce facts.
Effective communication skills
Identifying coping strategies
Personality types - Passive – Assertive – Aggressive
Fundamentals of an assertive personality
Anger styles and anger diary
Setting goals and roadblocks
Roadblocks roleplay exercise
Responding with empathy
Asking for help, types of help, support systems
Life is a test … It is only a test …
Goal planning worksheets
Sleep management
Divorce myths and facts
10. Art Therapy
This section should include information on art therapy including purpose and goals. It also includes handouts on art components, art history on each art piece to be used, a list of art activities, and art history videos, readings, networks and artists. Also condensed one page handouts for participants.
What is Art Therapy?
Art Therapy session purpose and goals
330
Page 8/Appendix H/Checklist …
Checklist for the therapist/counsellor
Creative components – Quaich, Mandalas, Pimawitisin Wheel, Masks
List of art activities
Art history video/readings/materials list, networks, artists
Keeping a creative journal, Creative journal resource book
12. Media
This section includes elements for use to explore the role of the various media so that participants can develop media literacy (see Appendix J for the whole package).
Media literacy
Media activities
Tools for deconstructing media images and checklist
Tips for becoming a critical viewer
Media quiz and answer key, Media questions
Magazine Ad review sheet
Political advertising campaign letter
Media literacy categories – Portrayal of women in the media
Attractiveness questionnaire
Facts on the media
Female role models list
Name your role models list
Alternative media internet sites
331
Page 9/Appendix H/Motivational …
13. Motivational
This section contains a series of one page handouts that can be used through the program as food for soul. Most individuals would want to include items from poetry and readings that are meaningful to them.
Everybody is a somebody
I am ….
God’s Footprints …
We wish to the new child …
Eulogy activity …
The Becoming …
Dedicated to the ego …
One day my soul just opened up …
Masks: An epilogue …
The elephant in the room …
What do you see Nurse? What do you see …?
How do I love thee …
Do not go gentle into that good night …
Malicious thoughts …
The lie I do not tell …
Heaven’s here on earth …
The courage to be myself …
What is respect and courage …
332
Page 10/Appendix H/The Invitation …
The Invitation …
To a sad daughter …
14. Survivor Stories
These survivor stories were written by individuals or their parents as inspirational and motivational accounts of the strategies and tools they used to overcome an eating disorder. I choose these because they are one or two pages long and could be used either to read to the participants within sessions, for individuals within the group to read to each other, and as components of the resource package that is provided for each individual.
They are to be found in Pipher’s books Reviving Ophelia and Surviving Ophelia.
Grounding in personal experience
Grading oneself Malinda Filingham
Time away Erika Hess
Step by step Michele Earl
A really bad dream Ellen Dellasega
Daddy dies Bernadette Mayer
Trying to survive Ellen
Hiking boots Rochelle Shapiro
Changes of struggles Anonymous
Time connection Tammy Bird
On my own Leslie Fabian
Nothing but the truth Pamela Cowell
Brandy is fourteen Laurent Fowler
333
Page 11/Appendix H/Struggling through …
Struggling through Lori Lipin-Keeley
How could I do anything different? Debra Kwartney
Mother lost Lynne Nebraska
A miracle for two Trudy Nelson
In my footsteps Anonymous
Mothering Ophelia Elizabeth Stein
15. Evaluations
Intake information form
Intake information questionnaire (Adolescent)
Individual Session Notes
Group Session Notes
Topic Evaluation Form
Program Evaluation
Therapist Evaluation Form
16. Resources
Eating Disorder Research Centre Resources (2005)
334
APPENDIX I
Psychoeducational Resources
Honouring Acceptance Worksheet (Sample)
Receiving without criticism or judgement. You do not have to like what is going on in your life, but you must accept that it is going on. If you don’t accept reality you are powerless to change things. Failure to accept reality is a denial that you have the power to make a conscious choice. When you do not choose you live by default and are carried along on some other agenda, you become a victim of circumstance. Honouring acceptance is acknowledging sometimes that nothing makes sense, but everything is, and will be, just fine.
Acceptance is simply recognition of all your experiences and accepting that you have the power to change things if you so choose. Accepting something does not mean you approve, that you are not impacted by it, it just means that you are able to remove the emotional attachment long enough to really see what is going on and make a wise choice. You are moving from a fantasy you have created into the real world of truth and it usually is accompanied by something secret being revealed to you. You are demonstrating an act of courage and showing the ultimate respect for yourself and others. It honours the wisdom, strength and tenacity of the spirit within you. Without the emotional charge of anger, fear or victimization it is easy to accept the reality of your life. By accepting what is you become keenly aware of what isn’t. When you know what isn’t you begin to determine what you need to do.
It requires trust and patience. Trust that you will make the right choices for you and trust that the universe will provide you with what you need to accomplish the task. You need patience because the task may not be easy, you need patience when you get angry or afraid, patience when you are tempted to lie to yourself and not accept the truth, and patience when it seems that nothing is going right. Clarity will follow and you will know what is right for you and what is not right for you (Vanzant, 1998).
Acceptance is a sign of courage Acceptance empowers me to make a conscious choice. Acceptance of what is does not mean liking it. Choosing in fear is not acceptance. Choosing in anger is not acceptance.
After reading today’s commentary I realize ……
The key phrase I want to remember and work with today is ……
Today, I realized that I resist ACCEPTING reality when ……
Today, I was able to ACCEPT that I …
335
Honouring Affirmation
It is holding steadfast in mind or speaking aloud a statement to claim or appropriate that which is true. Whatever you say to yourself today, let it be something good. Identify your good features and compliment yourself on your strengths, skills, positive attributes. If you don’t believe there is anything about yourself worth complimenting, repeat a compliment someone else has given you. Make a habit of beginning each day by telling yourself nice things. Remember all the victories you have had and the nice things you have done for other people. Remember a time when you experienced love or joy or pride in your accomplishments. Flood your mind with positive thoughts about yourself. Honour yourself by doing something nice for yourself. Buy yourself a small gift. Offer a prayer for yourself. Hug yourself. Spend time listening to your own self-affirming thoughts or words and weed out the negative chatter that races through your mind. You are worth five minutes, three times a day. It is food for the soul and necessary nourishment for the spirit. Your job is to take steps to affirm yourself several times in every day.
Poet Maya Angelou said that the power of words are like energy pellets that shoot forth into the universe and stick to the walls, furniture, the curtains and our clothing. Words seep into our being and become part of who we are. Self-affirming words and actions are necessary to counteract the unpleasant things we have heard about ourselves (Vanzant, 1998).
I am … I am a divine instrument of universal power! I am a divine reflection of universal love! I am whole and complete! I am unlimited and abundant! I am capable! I am joy in motion! I am the greatest miracle in the world! I am all that I am and life is graced by my presence. The truth of who I am cannot be altered or changed. The way I treat myself determines how others will treat me.
After reading today’s commentary I realize…
The key phrase I want to remember and work with today is …
The negative self-talk I heard today was …
It is difficult for me to think good thoughts about myself when …
The good things I know about myself are …
336
Honouring Conservation
Conservation requires a willingness to be physically, mentally and emotionally still. When we learn the value of who we are and what we have, we become mindful of conservation. Conservation begins with honouring yourself enough to spend some time with you away from everyone else. Conservation is a form of healing that results in self- awareness, self forgiveness and self-esteem as you learn to heal yourself from destructive behaviour patterns and the healing of your belief system. Conservation of your resources helps you give your best when you are giving, doing or being. Pace yourself, don’t rush, don’t compete. Spend time in a state of mental, emotional and spiritual relaxation, knowing that everything will get done according to the divine laws of the universe. You are a divine natural resource. Life wants you to be around for a long, long time. Life wants you to be in good shape while you are here. You are no good to life, when you are tired, exhausted, or broken. Learning to relax and converse your natural energy and resources is one of the greatest gifts you can give yourself (Vanzant, 1998).
I am a valuable resource! Conservation is a process of self-healing. Conservation builds self-esteem. Conservation is a necessary stage of personal growth. I deserve to rest. What I give to myself, I give to the world R-E-L-A-X!
After reading today’s commentary, I realize ...
The key phrase I want to remember and work with today is …
Today, I found it was difficult to relax when ……
I must learn to CONSERVE my time/energy/resources as they relate to …
I made progress toward CONSERVING my time/energy/resources today by …
337
APPENDIX J
Psychoeducational Resources
Media Package (Sample)
Below is a sample of media literature that is included in the psychoeducational package that supports these workshops. They are shown in the original format.
Media
Media literacy
Media activities
Tools for deconstructing media images and checklist
Tips for becoming a critical viewer
Media quiz and answer key, Media questions
Magazine Ad review sheet
Political advertising campaign letter
Media literacy categories – Portrayal of women in the media
Attractiveness questionnaire
Facts on the media
Female role models list
Name your role models list
Alternative media internet sites
338
MEDIA LITERACY
Lesson Goals: This lesson aims to first, introduce individuals to themes and/or messages about body image and health presented to us by media. Second, this lesson aims to teach us how to critically analyze media messages.
Goals: 1. All media are constructed – The media do not present simple reflections of external reality. Rather they present carefully crafted constructions that reflect many decisions and result from many determining factors. Media literacy works towards deconstructing the constructions, and taking them apart to show how they are made.
2. All media construct reality – The media are responsible for the majority of the observations and experiences from which we build up our personal understandings of the world and how it works. Much of our view of reality is based on media messages that have been pre-constructed and have attitudes, interpretations and conclusions already built into them. The media, to a great extent, give us our sense of reality.
3. All media have social and political implications. Audiences negotiate in the media. The media provide us with much of the material upon which we build our picture of reality, and we all “negotiate” meaning according to individual factors: personal needs and anxieties, the pleasures or troubles of the day, racial and sexual attitudes, family and cultural background and so forth.
4. At least some of the time mass media are skillfully produced and pleasurable (Worsnop, 1994). The media have commercial implications. Media literacy aims to encourage an awareness of how the media are influenced by commercial considerations, and how these affect content, technique and distribution. Most media production is a business, and must therefore make a profit. Questions of ownership and control are central. A relatively small number of individuals control what we watch, read, and hear in the media.
5. Media contain ideological and value messages – All media products are advertising, in some sense, in that they proclaim values and ways of life. Explicitly or implicitly, the mainstream media convey ideological messages about such issues as the nature of the good life, the virtue of consumerism, the role of women and men, the acceptance of authority, and unquestioning patriotism.
***The goal of this topic is to focus on the messages advertisers are selling in the name of profit and also the impact these messages may have on a largely unsuspecting public in relation to body image and self-esteem.
339
Page 2/Media literacy/Purpose …
Purpose: 1. To recognize disordered eating as a range of behaviours and that some of the less serious behaviours can ultimately lead to more serious consequences. 2. To identify the many, complex reasons why someone might struggle with an eating disorder.
Background: The media sells images of normalcy. It makes people think that to fit in with others they need to look like, behave like, eat like, and dress like the people presented in the media. Advertisers suggest that buying a particular product will help an individual achieve this imitation goal. For most people, however, attaining this “ideal” image is not only impossible, it is unhealthy and can be deadly. Trying to attain this unrealistic and unhealthy ideal can lead to a person feeling disconnected from her/his body and food is then offered as a way to reconnect (Jean Kilbourne).
Themes and/or messages about body image: It’s not who you are , it’s about how you look; There is no range of body shapes and sizes’ Only young, thin and white is beautiful; All teens dress sexy or provocatively; Female power comes from what a female’s body looks like and how she dresses; Fat people are (overweight); Fat people are unhealthy and thin people are healthy; If you eat right and exercise you can be thin; Diets work; A person’s weight is the most important if not the only aspect of a person’s health and wellbeing.
Outline: What is body image and what impacts how a person feels about her/his body? Linking body image or how a person feels about his/her body to the types of behaviours he/she might engage in; General overview of the continuum of disordered eating and the reasons why someone might be struggling; Move into the focus on media literacy; Video, quiz & activities; Discussion
Materials: Video: Suitable for the audience Magazine pictures: provocative advertising to generate discussion
340
Page 3/Media literacy/Handouts …
Handouts: Focused to the needs of the group
Body Image: An individual’s experience of his/her body. It is the mental picture a person has of his/her body as well as the individual’s associated thoughts, feelings, judgements, sensations, awareness and behaviour. Body image is not a static concept. It is developed through interactions with people and the social world, changing across the lifespan in response to changing feedback from the environment (Best Start: www.opc.on.ca/beststart/bodyimg, 2003.
341
MEDIA ACTIVITIES
Activity:
What impacts a person’s body image?
Judgements or comments from others; Sexual and racial harassment; Prevailing social values; Physical changes in the body during puberty; Violence – verbal, physical or sexual abuse; Conditions of the body – illness or disabilities. Media; Advertising industry; Dieting industry.
Use a board and pad to write down different ideas that individuals have. Acknowledge that body image is complex and there are many different factors impacting how a person feels about herself/himself.
Continuum of Disordered Eating: Starts with normal eating habits and moves toward severe obesity or thinness and diagnosed as “disordered eating” or an eating disorder.
Disordered eating are those attitudes, beliefs and behaviours that result in a range of dysfunctional coping strategies. These coping strategies include over/under physical activity, eating in irregular and chaotic ways, dieting, emotional eating, and eating disorders. The normal controls of hunger and satiety are removed and an individual eats to try to reshape his/her body or to relieve stress, fear or anxiety.
1) Discussion topic:
“Why might someone struggle with disordered eating or an eating disorder?
Comparing themselves to media images; Problems at home (divorce, abuse); Encouraged to diet by friends or family; Traumatic experience; Being targeted in school.
2) Discussion topic:
1. All media are constructed; 2. All media are linked to commercialism and consumerism.
342
Page 2/Media activities/Marshal …
(Marshal McLuhan’s assertion “The medium is the message!”
Question: “How might television and magazines shape the kind of information you receive?”
The intrinsic nature of the technology of television and of magazines as a form of communication dictates content.
Example: American idol’s Ruben Studdard. He is not the typical “idol/ideal” yet he won the contest with the fans voting for him. The idol maker, Simon Cowell, as a rule would not have considered Ruben because he is a fat man.
Questions: “What is being said through the images you see?” “What is being said in a Britney Spears video?”
Purpose: 1. To identify how, in today’s culture, the type of media technology used impacts the content of the information we receive. 2. To identify how communication is taking place through media images and to consider what is being said.
3. Discussion Topic:
Question:
“All media have social and political implications.”
Divide the group in half. Ask one half of the students to mark down what they believe to be the characteristics of the “ideal” female and ask the other half of the group to mark down what they believe to be the characteristics of the “ideal” male.
“Ideal female” “Ideal Male” Thin Big muscles Young Tall Big boobs Dark Nice “tush” Nice “tush” Fit Funny Blond Successful Popular Smells good Toned Blue eyes Well groomed Has a car Etc. Etc.
343
Page 3/Media activities/Purpose …
Purpose: To identify the impossible perfectionism of the “ideal” image.
Question: What is the percentage of people who can naturally look like the “ideal”? Naturally meaning without excessive exercising, restrictive eating or cosmetic surgeries.
Answer: 5% approximately!
Video: Confident for life: Kids and body image.
Question: Why are computer modifications made to images? Answer: To sell products.
Question: “How might the pressure to live up to this ideal impact a person’s behaviour?
Answer: Dieting, exercising, skipping meals, bulimia, anorexia nervosa, compulsive eating, bingeing, purging, laxatives, supplements, lost potential.
Purpose: To link the impossible standards of beauty promoted by our culture’s media, prompted by companies selling products, to how a person feels about her/his body and to the types of behaviours he/she might engage in because of negative feelings generated.
Question: “Is the development of body image dissatisfaction just the individual’s problem? “Is there just something physiologically wrong with the person that develops a negative body image?
Answer: Advertising sells the idea of normalcy’ We live in a culture that promotes an “ideal” image of what it means to be a female and what it means to be a male. Dieting, exercising, purchasing products to look better, doing what it takes to fit in is a normalizing strategy. Not liking one’s body is considered “normal”; The media focuses on the individual as having the “problem” and not the society in which we all live.
This can keep people from lobbying for change in the social world. Accurate health information, negative impact of dieting, and changing advertising practices aimed at children, youth and adults.
344
Page 4/Media activities/Discussion topic …
3. Discussion topic:
Statement: All media have social and political implications
Question: “What happens to the content of information we receive when the goal of advertising is commercialism not accurately informing or educating the public?
Answer: The influence advertisers have on editors and publishers to dictate content is dramatic. A magazine that receives 250 thousand dollars in advertising revenue is unlikely to print an article that challenges the goals and ideals of the company spending this money to promote their product.
A loss of democracy occurs. Individuals are sold the belief that freedom is the right to buy things and democracy is the ability to choose from several different consumer products.
Fat phobia and fat prejudice.
345
Tools for deconstructing media images:
Explain the concepts of implicit, explicit and context.
Explicit: Clearly and openly stated or defined, no hidden innuendo; Implicit: Understood although never stated directly; Context: The conditions or circumstances which affect how something is interpreted.
Statement: Using advertising examples explain an explicit message, implicit message and the context in which each of the advertising was developed and how it can be used to sell products.
Activity: Separate the group into twos or threes and give each a magazine advertisement and an activity sheet. After ten minutes have one person from each group explain to the class what they believe to be the implicit or explicit messages of the advertisement.
Follow with a discussion.
Videos: Killing us softly, Jean Kilbourne Beyond killing us softly, Jean Kilbourne Merchants of cool
***Each video offers a different look at media messages and the content of the presentation is tailored depending on the video used.***
346
TIPS FOR BECOMING A CRITICAL VIEWER OF MEDIA
Media messages about body shape and size will affect the way we feel about ourselves and our bodies only if we let them. One of the ways we can protect our self-esteem and body image from the media’s often narrow definitions of beauty and acceptability is to become a critical viewer of the media messages we are bombarded with each day. When we effectively recognize and analyze the media messages that influence us, we remember that the media’s definitions of beauty and success do not have to define our self-image or potential.
To be a “Critical Viewer” remember: All media images and messages are constructions; They are NOT reflections of reality; Advertisements and other media messages have been carefully crafted with an intent to send a very specific message; Advertisements are created to do one thing: convince you to buy or support a specific product or service. To convince you to buy a specific product or service, advertisers will often construct an emotional experience that looks like reality. Remember, you are only seeing what the advertisers want you to see. Advertisers create their message based on what they think you will want to see and what they think will affect you and compel you to buy their product. Just because they think their approach will work with people like you doesn’t mean it has to work with you as an individual. As individuals, we decide how to experience the media messages we encounter. We can choose to use a filter that helps us understand what the advertiser wants us to think or believe and then choose whether we want to think or believe that message. We can choose a filter that protects our self-esteem and body image.
To help promote healthier body image messages in the media: Talk back to the TV when you see an ad or hear a message that makes you feel bad about yourself or your body by promoting only thin body ideals; Write a letter to an advertiser you think is sending positive, inspiring messages that recognize and celebrate the natural diversity of human body shapes and sizes. Compliment their courage to send positive, affirming messages. Make a list of companies who consistently send negative body image messages and make a conscious effort to avoid “buying power” to protest their messages. Tear out the pages of your magazines that contain advertisements or articles that glorify thinness or degrade people of larger sizes. Enjoy your magazine without negative media messages about your body. Talk to your friends about media messages and the way they make you feel.
347
CHECKLIST FOR DISCERNING IMAGES AND MEANING
Check Off any of the following characteristics associated with your ad:
success (wealth or status);
Consumption (displaying expensive items)
Physical appeal (attractive, sexy);
Love, marriage, family (responsible, committed);
Ordinariness (simple, down-to-earth)
Extraordinariness (amazing performance, different);
Bandwagon (everyone has it, is using this product);
Magic ingredients (an amazing ingredient makes the product special, better
than any other);
Testimonial (Famous people promoting the product);
Wit and humour (diverting your attention by making you laugh or be
entertained by clever use of visuals or language);
Patriotism (buying this product shows you love your country);
Glittering generalities (“Weasel words” used to suggest a positive meaning
without making any guarantees).
Questions:
“What product is being sold?”
“What is the message of the ad?”
“It is more implicit or explicit?”
Followed by discussion.
Eating Disorders Resource Centre
348
‘DEADLY PERSUASION” - QUIZ THE ADDICTIVE POWER OF ADVERTIZING
Jean Kilbourne argues in her new book Deadly Persuasion that there is really no escape from advertising because advertising IS our environment. We are saturated by advertising. It’s on the radio, in magazines and newspapers, on the internet, billboards, sides of buildings, on and inside buses, subways, trucks, clothing and bumper stickers! Questions: 1. How many hours of television will the average North American girl watch before she starts kindergarten? (2000 hrs) (3000 hrs) (4000 hrs) (5000 hrs)
2. How much money do teenage girls and young women spend annually on cosmetics? (2 million) (4 million) (1 billion) (4 billion).
3. How many times a day is the average North American exposed to advertising? (1000 times) (2000 times) (3000 times) (5000 times)
4. How many ads will you see by the time you are 19 years old? (3 million) (4 million) (5 million) (10 Million)
5. How much of your life is it estimated that you will spend watching television commercials? (1 year) (2 years) (3 years) (5 years)?
6. What percentage of the editorial content in teen magazines focuses on beauty/fashion? (20% (35%) (50%) (70%)?
1. Which of these companies make huge sums of money by using demeaning images of women and girls in advertising? (Guess) (Deisel) (Dior) (Calvin Klein) (All of them)?
8. Five companies control nearly all of the entertainment industry in North American? (True or False)?
9. Magazines print information about weight loss next to boys and relationship info? (True or False)?
10. Who plays a larger role in creating media girls see and hear about? Men or Women?
1. Has the amount of newspaper coverage of women’ sport kept pace with the popularity and growth of female athletes? True or False?
2. Does the media represent the multicultural society we live in?
Discussion Questions: What did you learn from the quiz? What was surprising? How can you protect yourself from falling prey to the media trap?
349
QUIZ ANSWER KEY
1. 5000 2. 4 BILLION – Girls and young women are primarily told by advertisers that what is most important about them is their clothing, their bodies and their beauty. Girls of all ages receive the message that they must be flawlessly “beautiful” and above all else they must be thin. 3. 3000 times every day 4. 10 MILLION – You are the most marketed group in the history of the world, you’re the biggest group of teens that ever lived on the planet, so there is a ton of money to be made from you. Brands compete for your dollars. Marketing companies create something that is “cool” but cool keeps changing. Cool hunting is looking for the 20% of kids who will influence the other 80%. Trends make billions! Trends eventually die out so there is constant pressure to create new ones. 5. 3 YEARS 6. 70% - Magazines are the only medium in which girls are over represented. Almost 70% of the editorial content in teen magazines focuses on beauty and fashion, and only 12% talks about school or careers. 7. E - All of them. These advertisers make money using limited, unrealistic and demeaning images of women. Unfortunately many consumers buy products from these companies without realizing that their dollars actually help to perpetuate negative imagery of women. Five enormous companies sell almost all of youth culture. Newscorp, Disney, Viacom – at least 40 other huge companies including blockbuster video, to CBS, BET, VH1, MTV, Paramount studios and theme parks, Star Trek franchise in U.S. Universal Vivendi, AOL/Time Warner.
These companies own 90% of all the music companies: - all or part of commercial cable channels - run all US film studios - Movie theatres - Most TV stations - All News stations. Viacom is the most successful, mostly because of MTV which earned a billion dollars in profits in 2000. MTV is a youth marketing empire – everything is a commercial or infomercial on MTV; a video for a music company, clothes/look on the set, show on an upcoming movie, everything on an infoSprite.com party was filmed by MTV and broadcast on MTV. Sprite rented out facilities, payed kids $50 dollars to come, rap artists got a plug on an MTV show for which Sprite was the sponsor. Cross promotion going on all the time.
8. True – Messages about weight loss are often placed next to messages about men and relationships. Some examples include “Get the body you really want.” Beside “How to get your man to really listen” and “Stay skinny paired with “what men really want.”
350
Page 2/Media Quiz Key Answers ……
9. True
10. Men – Few women create the media girls see and hear. Women account for only 24% of the creators, producers, executive producers, directors, writers, editors and directors of photography working on situation comedies and dramas in 2000/2001. 11. No – The amount of newspaper coverage of women’s sports had not kept pace with the popularity and growth of female athletics. A study that compared coverage of women athletics in 1989 and 1999 showed that girls and women received just 2.2 % of all sport coverage in 1989. Then years later, when women make up nearly 40% of all high school, college and Olympic athletes, women received 6.7% coverage! 12. No – Media programming creates environments that influence young people on how to interpret and act toward people similar to and different from them. On screen representation of women during prime time in TV 2000/2001 season: shows 74% Caucasian, 16% African, 4% Asian, 2% Hispanic.
***Viewers are more likely to see an apparition female (such as a ghost or angel) than they are to see a girl or woman portrayed as a Hispanic or Native American character.***
You are the most targeted and “marketed to” group in the history of the world. You’re the biggest group of teens that ever lived on the planet. There is a lot of money to be made from you. Brands all compete for your dollars. But apparently, you are a frustrating market because you are less responsive to brands, versus kids in the late 20th Century. It was estimated that U. S. companies spent nearly $200 billion on advertising in 1998. Some of that was devoted to doing market research to find out what will make teenagers buy stuff. What do you think they found out? You do respond to “cool”, but “cool” keep changing. Cool-hunting means looking for the 20% of kids who are ahead of the pack, because they influence the other 80%. Page 2/Media quiz key ……
If companies can get onto a trend before it goes mainstream, they can make billions of dollars. The trend will eventually die once it hits full mainstream, so there is constant pressure to find the next big thing.
McKenna (2005)
351
MEDIA KEY QUESTIONS
Question: What do you think is cool now? What do you think will be the next big thing?
Question: What impact do you think this concentration of images in a few hands has on teens?
The Mook and the Midriff – Maybe a couple of years old by now so it may have changed, but 2001 was the Mook and Midriff phase.
“The Mook” – crude, loud, obnoxious, and in your face – Tom Green, Jackass, frat boys, spring break specials, the Man Show guys. Most bankable creation of Viacom. Replicate it! For example, Howard Stern is thought to be a mook (an old one – has anybody heard of him?). He is syndicated on 50 stations, weekly TV shows, books published, movies produced by him, sold at Blockbuster video – all by Viacom.
Question: Are there many people out there actually like that? How do you know this? Why do you think the media is interested in perpetuating this stereotype?
The “Midriff” – no more true to life than the Mook. So whereas the Mook is arrested in adolescence, the midriff is prematurely adult. He doesn’t care what people think, whereas she is consumed by appearances. If his schtick is crudeness, hers is sex. “The midriff is a collection of the same old clichés but repackaged as a new kind of female empowerment.” I am a sexual object and proud of it!
Question: Who do you think have been powerful icons for The midriff? What is the message of this stereotype? (Your body is your best asset! Flaunt your sexuality, even if you’re unsure about it. When Britney was hot, teenage girls were her biggest fan base. Is this stereotype changing?
Question: Do you think that sexuality/sexual situations are becoming more and more overtly displayed/marketed to teen audiences than before?
***A study done by Silverstein et al (1986) showed that in comparing four of the most popular women’s magazines of the day and four men’s popular magazines of the day, there were 63 more diet ads in women’s magazines. There was only one in the man’s.
Question: Why do you think that is? Do you think that has changed recently i.e. more targeted to both etc?
352
Page 2/Media questions/There …
***There are more alcohol and alcohol-related ads in magazines that cater to the African American or Asian populations. Tobacco companies have also targeted black consumers as their major markets.
Question: Why do you think that is?
***In Canadian news, women in politics are often sidelines in newspapers and magazine coverage because the coverage often tends to focus on the details of her personal life rather than on the issues she is speaking to. (Association of Women Journalists, 2000)***
Question: Why do you think that is? Do women not make news? Are their stories less important? Why the focus on domestic aspects. What does that say about women’s roles?
Margaret Duncan watched countless sports events and the commentators (97% of whom were men) more often referred to women as “weary, fatigued, frustrated, panicked, vulnerable and choking). Commentators were also twice as likely to call men by their last names only, and three times as likely to call women by their first names only.
Question: what do you think is the effect of this? Does it reduce female athletes to the role of children while giving status to male athletes?
Other Questions: How do you think teens are portrayed in the media? What don’t you see? What is missing? What are the differences in media between the US and Canada? - Gap is narrowing with US influence/US corporations merging and pulling ahead. - Can mean loss of language, tradition, or cultural heritage, lack of diversity, cultural homogenization. - Dissenting voices are censored out.
Adapted from information from the public domain of the internet.
353
MAGAZINE AD REVIEW
Look through a magazine for the following information:
1. Number of pages in the magazines ______
2. Number of advertisements in the magazine ______
3, Number of advertisements including women ______
1. Number of ads using a woman to sell their product ______
5. Number of ads showing only parts of a woman’s body ______
6. Number of ads using specific words to sell their product which may refer to the way a woman looks or feels e.g. Virginia Slims, you’ve come a long way baby. ______
7. Number of ads showing an average or large size woman ______
***Use DOVE ads to talk about the campaign for real beauty*** Cast your vote online at www.campaignforrealbeauty.ca.
Adapted from Peel Health (1991) Dating and relationship presentation kit.
354
Sample comment letter
Don’t forget to include the date, your name, address and telephone number. Anonymous letters are not taken seriously. If you write a letter to the editor, make sure to include your telephone number since most papers call people who submit letters before they will publish them
Ms. Suzanne Keller Canadian Advertising Foundation 350 Bloor Street East, Suite 402 Toronto, ON M4W I H 5
Dear Ms. Keeler:
I am writing to express my concern about a recent advertising campaign that has appeared in the March 1999 edition of Vancouver Magazine and is portrayed on Greater Vancouver buses recently.
The ad for “Almost Heaven” clothing depicts a woman, unclothed, with her back facing the viewer and arms outstretched with five hangers loaded down with clothing from each of her arms. This ad blatantly objectifies a woman, turning her into a clothes rack. It is obvious that this woman’s body is being used to attract the attention of the consumer as the clothing is barely visible. Moreover, this woman is not portrayed in “a manner which reflects her emotional and intellectual equality and which respects her equal dignity” as this contrived position would obviously involve considerable discomfort and pain.
I hope you will assist us in getting this ad removed. I look forward to your prompt response.
c.c. Trans ad, B. C. Transit Commission, Vancouver Magazine, Media Watch.
***B. C. Transit pulled this campaign and then consulted with Media Watch in the development of sexual stereotyping guidelines which are still in use today. The ad did not reappear in local print media either.***
Permission to reprint granted by Media Watch.
355
MEDIA LITERACY CATEGORIES Portrayal of women in advertising
Using a video or magazines to suggest that they consider “What is problematic about some of these?
Alcohol – seen as a “chick magnet” - promises excitement, sexual pleasure etc. Body parts – How many times do you see disembodied legs, breasts, feet? Dummies/dolls/mannequins – women as inanimate objects – What does that imply? Do they talk? Do they move? Are they just decorative? Are they just a dumb mannequin to hang clothes on? Do they have a personality? Emaciation – thin ideal, uber-thin ideal. Magazine pseudostories – What is the story saying in the visual? What just happened? What is about to happen? Sex – How many times do you see women using sexuality to sell products? Notice how “sex” is often equated with women’s bare bodies – much more so than men. How often are bottles, shapes used as subliminal sexual messages etc? Women and visual height – How often are women lying in a prone position? How often are they depicted as vulnerable? Or dead? Surgery – How often do the ads capitalize on women’s discontent with their bodies. Tobacco – smoking keeps you “slim” myth? Having a smoke after sex scenario. Violence against women – creepy, menacing atmosphere of image, overt images of violence or death? Woman on woman violence, catfights, often in competition for a man?
What do you think of cat fights? Often sexualized to fulfill male fantasies.
Weight loss – Pursuit of thin beauty ideal Women of colour – racial stereotypes (e.g. black mama, Indian princess, hot-blooded Hispanic, submissive Asian Geisha? Women of colour as having animal tendencies? As highly sexualized in (rap videos). Women naked – Ads that make women look stupid, airheaded, blond? Young girls – sexualization of girls, girls made to look adult, pageant phenomenon?
McKenna (2005)
356
ATTRACTIVENESS questionnaire ……
Please read these questions and circle the number and words that best match your agreement with the following statement:
1. I learn how to look attractive by watching TV. Definitely Mostly Neither agree Mostly Definitely Disagree Disagree nor Disagree Agree Agree 2. When I watch sports on TV, I compare my body to the bodies of the athletes. Definitely Mostly Neither agree Mostly Definitely Disagree Disagree nor Disagree Agree Agree 2. Watching movies makes me feel that attractive people are more successful than unattractive people. Definitely Mostly Neither agree Mostly Definitely Disagree Disagree nor Disagree Agree Agree 4. I would like my body to look like the bodies of people in the movies. Definitely Mostly Neither agree Mostly Definitely Disagree Disagree nor Disagree Agree Agree 5. Watching movies gives me ideas about how to look attractive. Definitely Mostly Neither agree Mostly Definitely Disagree Disagree nor Disagree Agree Agree 6. Looking at magazines makes me want to change the way I look. Definitely Mostly Neither agree Mostly Definitely Disagree Disagree nor Disagree Agree Agree 7. I compare my body to the bodies of athletes that I see in magazines. Definitely Mostly Neither agree Mostly Definitely Disagree Disagree nor Disagree Agree Agree 8. Reading magazines makes me want to lose or gain weight. Definitely Mostly Neither agree Mostly Definitely Disagree Disagree nor Disagree Agree Agree 9. I get hints about how to look attractive by reading magazines. Definitely Mostly Neither agree Mostly Definitely Disagree Disagree nor Disagree Agree Agree 10. Watching TV shows makes me believe that thin people are more successful than overweight people. Definitely Mostly Neither agree Mostly Definitely Disagree Disagree nor Disagree Agree Agree 11. Reading magazines makes me want to change my appearance. Definitely Mostly Neither agree Mostly Definitely Disagree Disagree nor Disagree Agree Agree 12. I learn to look attractive by watching movies. Definitely Mostly Neither agree Mostly Definitely Disagree Disagree nor Disagree Agree Agree 13. I would like my appearance to be like the appearance of people in the movies. Definitely Mostly Neither agree Mostly Definitely Disagree Disagree nor Disagree Agree Agree
357
Page 2/Attractiveness questionnaire/TV gives …
14. TV gives me ideas about how to improve my appearance. Definitely Mostly Neither agree Mostly Definitely Disagree Disagree nor Disagree Agree Agree
Adapted from the Eating Disorder Resource Centre (EDRC)
358
Facts on the Media
The media promotes and reflects the current mainstream culture’s standards for body shape or size and importance of beauty. The media reflect images of thinness and link this image to other symbols of prestige, happiness, love and success. Repeated exposure to the thin ideal via the various media can lead to the internalization of this ideal. It also renders these images achievable and real. Until women are confronted with their own mirror images they will continue to measure themselves against an inhuman ideal.
90% of all girls ages 3-11 have a Barbie doll.
In 1992, the ten most popular magazines most commonly read by men and women were reviewed for ads and articles related to weight loss. The women’s magazines contained 10.5 times more articles related to dieting and weight loss than men’s magazines (Andersen & Domenico, 1992).
Magazines such as Seventeen, Sports Illustrated, Teen, Ebony, Young Miss, Jet, Newsweek, and Vogue account for more than half of all reported reading of adolescents (Strasburger, 1995, p. 46).
A study of the content of Seventeen Magazine (the most widely distributed adolescent magazine) for the years of 1945, 1955, 1965, 1975, 1985, and 1995, found that in all issues the largest percentage of pages were devoted to articles about appearance (Schenker, Caron, Halteman, 1998).
In the 70’s, an analysis of Ladies Home Journal, McCall’s and Good Housekeeping Magazine revealed the dominant messages to be that marriage is inevitable for women, and that to catch a man a woman must be less competent than he, more passive and more virtuous (Franzwa, 1975).
Five popular women’s magazines were reviewed for their message regarding weight control messages and morality perceptions (Pongonis & Snyder, 1998). Morality messages have significantly increased in food, weight control and fitness articles and ads over the past 20 years, linking morality to food choices and body weight (such as morality messages alluding to lack of control, laziness and self-indulgence linked to higher weight).
A comparison of content for Ebony, Essence and Ladies’ Home Journal revealed that there is significantly higher use of alcohol and alcohol-related ads in the Black-oriented magazines (Pratt & Pratt, 1996). The tobacco companies also seem to have targeted Black consumers as their major market, as evidenced by their advertisements.
Analyses of advertisements have shown that males are much more often depicted as looking directly at women, than vice versa (Goffman, 1979, Umiker-Sebeok, 1981).
359
Page 2/Facts on the media/69% …
69% of female television characters are thin, only 5% are overweight (Silverstein, Peterson, Perdue & Kelly, 1986).
The average person sees between 400 and 600 ads per day –that is 40 million to 50 million by the time he/she is 60 years old. One of every 11 commercials has a direct message about beauty (not counting the indirect ones).
Silverstein and colleagues found that the years in which the number of women in managerial positions and professional positions increase, in the 20’s and late 60’s. The female body ideal as reflected in issues of Ladies Home Journal and Vogue became slimmer (Silverstein, Peterson & Perdue, 1986).
Another study found that 68% of a sample of Stanford undergraduate and graduate students felt worse about their own looks after reading women’s magazines (Burgard, 1991).
The tendency to compare oneself to models that are portrayed by the media, increases with age (Kennedy & Martin, 1995).
Irving (1980) found that subjects exposed to slides of thin models consequently presented with lower self-evaluations than subjects who had been exposed to average and oversize models. The results also show that all subjects experienced the greatest pressure to be thin from the media, followed by peers and then family.
Richins (1991) found that exposure to idealized images lowered subjects’ satisfaction with their own attractiveness. Stice and Shaw (1994) studied subjects’ reactions to pictures of thin models in magazines. Their results indicated that exposure to the thin ideal produced depression, shame, guilt, body dissatisfaction, and stress. Stice et al., (1994) found a direct relationship between media exposure and eating disorder symptoms.
Girls aged 14-18 were exposed to images of models (typical images of models and computer-altered images that were altered to appear “overweight). Girls exposed to the typical models evaluated themselves and their appearance more “overweight” compared to computer altered (Crouch & Degelman, 1998).
***Distinction between fantasy and reality becomes blurred by media*** Mass media is making it seem as if “perfection” is attainable with the right diet, the right beauty products, the right plastic surgery.
What we need is for young women to stand up and say “I’ve had it! Enough! Define your own standards of beauty. Ask yourself “What does beauty mean to me?” http://www.about_face.org/r/facts/media.shtml
360
FEMALE ROLE MODELS
Look or choose specific qualities, characteristics and/or accomplishments of a variety of women as empowering images:
1. Advocate Elizabeth Taylor, award winning actress. Despite unpopular public opinion was a supporter for AIDS research and education.
2. Artistic Maya Ying Lin, architect and sculptor. As a 21 year old senior at Yale University she entered a national competition to design Vietnam monument in Washington, D. C. Her design of a V- shaped black granite was chosen for its simplicity.
3. Athletic Florence Griffith Joyner. First woman athlete since 1948 to win three gold medals and a silver medal in the Olympic Games.
4. Compassionate Whoopie Goldberg, award winning commedienne who has led the war against homelessness.
5. Courageous Hannah Senesh, in 1944, was court martialed then brutally tortured and executed when caught trying to rescue the Jews from Hungary.
6. Forerunner Sandra Day O’Connor, first woman to be appointed to the U. S. Supreme Court (traditionally a male dominated world).
7. Leadership Wilma Mankiller overcame poverty, sexism, racism and illness to become one of the most respected leaders in the country. She has been Chief of the Cherokee Indian Nation since 1986.
8. Responsible for Mary Tyler Moore, an award winning actress and a woman Public awareness President of the Diabetes Foundation.
9. Risk Taker Rosa Parks, civil rights leader. Refused to give up her seat on a bus to w white man which triggered a boycott that resulted in the end of segregation on city buses in Montgomery. She is the Mother of the Civil Rights Movement.
10. Triumphant Gloria Estefan, singer, composer, musician and performer. Despite a near fatal car accident and serious injuries to her back during the height of her career, she made a miraculous recovery and continued to perform.
11. Environment Wangari Maatha, the first African woman to win a Nobel Peace prize for her work with Green Belt Movement for planting trees in Kenya. (Adapted from Eating Disorder Resource Centre)
361
ROLE MODEL IMAGES
Name your role models and why.
Personal:
1.______
2.______
Fictional: 3.______
4.______
Famous:
5.______
6.______
Literary: 7.______
8.______
Other:
9.______Note: I bring anorexia into the room in the shape of a stocking doll with wig and clothes, and I hand out small cut out coloured paper T-shirts for the girls to write a note to someone they would like to honour. Often it is their mother, or a public figure who has stood up to social pressures to be thin. I encourage them to talk about who they chose and why. By this time most of them will have something to say but again this public commentary is optional. They go through the ritual of pinning their note on the doll. Can be very moving for everyone. Cash, T. (1997). Body Image Workbook, Cash
362
IF I could have anyone’s …….
Hair ______Eyes ______Nose ______Mouth ______Chest ______Waist ______Hips ______Legs ______Face ______Personality ______
Adapted from information provided through the Eating Disorder Resource Centre (EDRC)
363
SOME QUESTIONS TO ASK YOURSELF TO DECONSTRUCT THE MEDIA
1. What is this ad really trying to sell me? (“cool”, a certain lifestyle, an unrealistic promise of meeting the beauty ideal?)
2. Who is getting rich from my buying this product?
3. Why to I want to buy this product?
4. How will buying this product really make me feel, realistically?
5. How has this advertisement been altered so that it does not necessarily reflect reality? (e.g. airbrushing, stretching).
6. How are women and/or men portrayed in this ad? Why do these advertisers want me to see this image?
7. What does wearing a brand offer me? What does it offer the makers of the product?
8. Other questions …….???
McKenna (2005)
364
ALTERNATIVE MEDIA SITES http://www.adbusters.org/frash.html - Culture Jamming http://www.nologo.org/ - Anti-corporate globalization, anti-branding site http://alternet/prg/ - A project of the Independent Media Institute, a nonprofit organization dedicated to strengthening and supporting independent and alternative journalism. www.indymedi.org – Great alternative media site. http://www/mp;pgp/prg/ - Anti-corporate globalization, anti-branding site http://www.alternet.org/ - A project of the Independent Media Institute, a non-profit organization dedicated to strengthening and supporting independent and alternative journalism. www.indymedia.org – Great alternative media site www.unbranamerica.org – Dedicated to culture jamming American branding, spoof ads, etc. http://www/mediawatch.com/ - Challenges abusive stereotypes and other biased images commonly found in the media. http://www.about-face.org/ - About face promotes positive self-esteem in girls and women of all ages, sizes, races and backgrounds through a spirited approach to media education, outreach and activism + Gallery of Worst Offenders in Advertising. http://oneangrygirl.net/ - Cool t-shirts http://www.guerrillagirls.com/ - Media activism http://www.bitchmagazine.com/ - Feminist response to pop culture magazine, incisive commentary on our media-driven world. http://www.medialit.org/reading_room/article65.html - Deadly persuasion: 7 myths alcohol advertisers want you to believe. http://www.medialit.org/reading_room/article40.html - Beauty … and the beast http://www/medialit.org/reading_room/article66.html - The selling of addiction to women.
365
APPENDIX K
List of Creative activities
Drawing, painting, tracing from the figure Drawing, painting, tracing portraits Mobiles from old blinds, tape, tissue, seeds Plaster casts, molds of various parts of the body Paper-mache, casts from Black Tea fungus Sculpture, plaster, paper-mache, old appliances, discarded objects Spontaneous sculptures, painting, drawing Portraiture using overheads, projectors, acetate pens Photography – still life, study of light, shadow, composition, drama Study of environment – writing, reading, collecting found objects Exercises in writing, reading, interpreting, manipulating the written word Poems, rhyme, doggerel on life and death, dying, living, humour Take a page of writing – highlight words, eliminate words, create a story Create a physical performance of an activity Mimic and mime – a walk, talk, mannerism Create a sculpture about “what stops the silence of a room?” Create a sculpture or installation on the meaning of death and dying Create a life or death diary Create an art piece that makes a public statement Create a drawing, painting or sculpture from legend, world religions Study videos/slides on famous artists and their medium Study various art “isms” – cubism, surrealism etc. Study videos on themes such as – birth, rebirth, myth, life, death Study art history/art criticism/art philosophy – what is beauty? Discuss art as social change/art for social change – public murals/graffiti Study body movement and how it works in the world Explore the environment with a camera/video camera Explore self, family, relationships, community, world, universe through art Explore the relationship between art and nature Respond to the unknown through language as metaphor – using the five senses plus intuition
366
APPENDIX L
List of Creative Activities with Cross Cultural Links
Masks
Lanterns
Kites
Life Wheels/Pimiwitiisin Wheels/Shields
Sand sculptures – Individual and group
Feeling Mobiles/Sculptures
Creative/Scrap/Story/Affirmation Books,
Boxes – Secrets, Symbols, Synthesis and Safety
Poetry/Prose/Writing
Rituals
Music – Pop/Classical/Ethnic
Making Drums
Making Didgeridoos
Drama – Greek, Noh, Shakespeare
Group Murals
Humour
Photography
Stories in Clay
Creating a Museum of Loss
367
APPENDIX M
The Quaich
The Quaich (pronounced “quake”, from the Gaelic word “cuach”) has a rich heritage and tradition in Scotland – in fact, it is a uniquely Scottish invention. The two-handed (known as lugs or ears) drinking cup has no other equivalent with other European drinking vessels. The quaich is also surrounded by myth and mystique.
For example, in ancient times (during the Celtic period), it is believed that the Druids filled the quaich with blood from the heart of sacrificed humans. It is believed that the first quaichs were simple scallop shells. The earlier crafted ones were originally made from wood and then various metals including silver and copper and evolved into a cup of various shapes and sizes.
Quaichs have become a mainstay at celebrations in Scotland such as weddings where the drinking from the quaich symbolizes the solemn acceptance of sacred vows, and they are used on special occasions such as christenings and graduations to honour a life passage. They often contain whisky or brandy that is passed between individuals as a welcoming gesture. Some quaichs were also used for ale (the largest surviving examples having the capacity of about 1.5 pints).
It is surmised that the purpose of the ancient shallow cup was to limit the amount of alcohol consumed and the two- handed offering and accepting of the cup was so that the clans could view their enemies hands at all times. The quaich held a special place in the heart of proud clan chiefs, worthy merchants and humble crofters alike.
Today, a quaich is a prized possession of all who know something of its history for many Scots (at home and abroad) and for many others who have an association with Scotland. It is revered as a traditional visitors’ welcome or farewell cup to join people in the ritual of shared love and partnership.
I used the quaich in opening and closing rituals with the eating disordered groups and found it helpful on a number of levels. I was able to offer them insight into my own cultural heritage by sharing with them the information around the use of the quaich. I filled it with stones (instead of whisky) and at the beginning of each session they were asked to pass the cup in a two-handed gesture, taking out a stone at the beginning that symbolized a hope that they had for that session. At the end of the session, the stones were gathered in and they were asked to place a worry on the stone. They could choose to verbalize their hope and their worry if they were comfortable with that, or they could silently perform the ritual. I would have the quaich set up somewhere in the middle of our area where we came together and it had the reaction of grounding people as they came into the space so that the space and the individuals could be honoured in a very simple, yet profound way in a practice that has been handed down over centuries. The whole process takes only two to three minutes.
368
APPENDIX N
Mandalas
The word Mandala comes from a Sanskrit word for a geometric figure in which a circle and square lie within each other, and each is further subdivided. It is also suspected to have originated in the Paleolithic period and to have spread widely throughout the Orient in early time, and then throughout the rest of the world in the present day. The mandala usually has religious significance and often visually symbolizes the whole world or healing circle. A mandala often appears in dreams both as a symbol of wholeness and as a compensatory image during times of stress (Jung, 1911/56).
The mandala is the most basic form in nature. Circles suggest wholeness, unity, completion and eternity.
The basic pattern of the circle with a centre is found in nature and is seen in biology, geology, chemistry, physics and astronomy. On our planet, living things are made of cells and each cell has a nucleus – they all display circles with centres. The crystals that form ice, rocks, and mountains are made of atoms. Each atom is a mandala.
Within the Milky Way galaxy is our solar system and within our solar system, is Earth. Each is a mandala that is part of a larger mandala.
Flowers, spider webs, and the rings found in tree trunks all reflect the primal mandala pattern. The “circle with a centre” pattern is the basic structure of creation that is reflected from the micro to the macro in the world as we know it.
The traditional mandala is a complex design that is used in religious practice for meditation or contemplation. The images are prescribed by tradition and are drawn, painted or modeled as in sand sculpture.
Mandalas in Art: The mandala pattern is used in many religious traditions. Hildegard von Bingen, a Christian nun in the 12th century, created many beautiful mandalas to express her visions and beliefs.
In the Americas, Indians have created medicine wheels and sand mandalas. The circular Aztec calendar was both a time-keeping device and a religious expression of ancient Aztecs.
In Asia, the Taoist “yin-yang” symbol represents opposition as well as interdependence. Tibetan mandalas are often highly intricate illustrations of religious significance that are used for meditation.
Sand Mandalas: Different cultures with similar expressions
369
Page 2/Mandalas/labyrinths …
Both Navajo Indians and Tibetan monks create sand mandalas to demonstrate the impermanence of life.
Labyrinths: are a type of mandala found in many cultures and are used as a tool for centering the mind and body. There are labyrinths all over the world that people can visit. More information can be found by typing in “labyrinth” on the internet. Here in Vancouver there are a number of them within easy access. One that comes to mind is at St. Paul’s Church, 1130 Jervis Street, Vancouver. (http://www/stpaulsanglican.bc.ca/labyring/news.shtml)
In ancient Tibet, as part of a spiritual practice, monks created intricate mandalas with coloured sand made of crushed semi-precious stones. The tradition continues to this day as the monks travel to different cultures to demonstrate the creation of the mandala and to educate people about the culture of Tiber.
Mandalas in the West: There is also a tradition of healing circles in the west. Powerful symbolism is seen in Native American sand paintings, medicine wheels and shields. Medicine wheels represent the universe, change, life, death, birth and learning. The great circle is the lodge of our bodies, our minds and our hearts. Although there are many parallels to the Tibetan mandala, Native Americans never used the word mandala to describe their sacred circles.
Carl Jung and Mandalas: The Western culture is familiar with Mandalas primarily because of the work of Carl Jung who became interested in them while studying Eastern Religion. Jung defined the mandala as a symbol of wholeness and the centre of personality. Each mandala is unique because it is a projected image of the psychic state of its author. In Jungian psychology, the mandala or magic circle is used in contemplation moving the spirit forward along the path of evolution from the biological to the spiritual. It is visualized in dreams symbolizing the dreamer’s striving for unity of self and completeness. Jung saw the circular images his clients experienced as “movement towards psychological growth, expressing the idea of a safe refuge, inner reconciliation and wholeness.” and is thought to have a non-spatial, non-temporal centre.
Connecting to the Mandala Circles are universally associated with meditation, healing and prayer. There are many ways to connect with mandalas. Numerous cultures have developed specific methods and added meaning to the process. Depending on whom you ask for a definition of mandalas, you get different answers.
For some people mandalas, and the making of them is a highly formalized art, for others they are a means of self-expression. There is no “right” way to make a mandala.
370
Page 3/Mandalas/The language of …
The language of mandala is symbolic. The colours and the images in an individual’s mandala will reflect their inner self. There is no rule that you have to use, and nothing to stipulate that you have to use certain kinds of colour, or certain types of material to create your own mandala.
What do you need to begin mandala work? First select your drawing material – you can use pencil, pastel, watercolour, markets etc. There is no right or wrong mandala. It is just a simple reflection of yourself at that moment of drawing. So ... Let instinct guide you to draw your mandala. After you have finished your mandala, give it a title, but don’t think too long or hard on that. You may also write down the date of creating it for your record. After that, take our a notebook or piece of paper to record the colours in your mandala, from the predominant colour to the least shown colour. Write down your feelings or memories in detail about each colour and image. When you are done compiling your list, you may discover something about your likes and dislikes. The mandalas that you create symbolize you. They are very useful for self-expression, self-healing and self-exploration and they can be used as opening and closing rituals i.e. starting from the inside and working out, or starting from the outside and working in.
371
APPENDIX O
First Nation Information
Canadian First Nations individuals are a heterogeneous group of 53 separate cultures. They represent 630 communities and are diverse in terms of degree of urbanness or ruralness, religious beliefs, traditionalism, assimilation etc. The difference between the Mohawk language and Assiniboine is about the same as the difference between Italian and Mandarin. Nevertheless, Canadian First Nations have some common factors that allow us to speak of these cultures. 1. They have been in North America for a very long time, and in our opinion are formed by the land; 2. They have all experienced the sequelae of colonization; and 3. Spiritual principles and values appear to be fundamental to success in therapy. 4. They believe in value-based intervention, interconnectedness, and listening for a deeper meaning in experiences. First Nations generally prefer direct, concrete, spiritually-based, culturally consistent approaches. They are usually big on picking up on non-verbal messages.
Reflect on the following questions: 1. What is your experience in life with Native peoples, or other indigeneous peoples? 2. What do you know of First Nation music? Some musicians to identify are Renae Morriseau, John Kim Bell, Winston Whattnee, Kashtin, Robbie Robertson, Susan Aglukark, Alanis Obosansawin. 3. What early traditional songs, prayers, pictographs, archaeological sites have you encountered? What do they mean? Are they different from today? 4. Identify cultural beliefs, practices and behaviours that are different from your own values? Where might they class? 5. How comfortable are you with silence? 6. How could you incorporate indigenous healing practices into your own life? What would they be? 7. What particular cultural practices or behaviours might challenge your cultural sensitivity? 8. Compare the world view of First Nations individuals with Western understanding of how the world works?
Records: Aglukark, S. (1995). This child. EMI. Black Lodge Singers (2001). Tribute to the elders. Phoenix: Canyon Records. Kashtin. (1989). Kashtin. Pointe Clair, QC: Musicor. Morriseau, Renai., Bell, John Kim., Wattne, Winston & Robertson, Alanis Obonsawin. Powwow music. Robertson, R. (1998). Contact from the underworld of Redboy. Cema/Capitol. Seventh Fire. (1993). The cheque is in the mail. Ottawa: socan.
372
Page 2/First Nations/Films …
Films: Hart, B. (Director). (1982). Wildfire: The Tom Longboat story. Toronto: Canadian Broadcasting Corporation. Kubrik, S. (Director). 2001: A space odyssey. Warner Studios. (A film based on a Navaho story about the living stone, the basis of creation.) Kunik, Z. (Director). (2002). Atanarjuat: Fast runner. Igloolik Isuma Productions. Obonsawin, A. (Director). (1993). Kanesatake: 270 years of resistance. Ottawa: National Film Board of Canada. Pollack, S. (Director). (1972). Jeremiah Johnson. Warner Studios.
Articles: Benton-Banai, E. (1979). The Mishomis book: The voice of the Ojibway. St. Paul, MN: Indian Country Press. Bopp, J., Bopp, M., & Lane, P. (1984). The sacred tree. Lethbridge, AB: Four Worlds Development Press. Storm, H. (1985). Seven arrows. New York, NY: Ballantine.
http://www.abcounsellored.net/courseware/caap607lessons8.html
373
APPENDIX P
Medicine Wheel
Medicine wheels and peace shields are a First Nations artistic expression where symbolism is used to tell a story that integrates daily life and myth. It typically is composed of messages using symbolic pictures. They may incorporate signs, symbols and myths that have been handed down orally over centuries, recommended by an elder or been passed along from the collective unconscious.
Figure #? – Arkansas Medicine Wheel
A peace shield is a personal object that is traditionally used during First Nations ceremonies which may look like a shield for battle but is a symbolic representation of who an individual is based on the Medicine Wheel. An example of an ancient medicine wheel can be found at – http://www.ari-aerc.org/dustdevil.html.
Directions Apply the use of symbolism in producing your own creative shield; Describe yourself using traditional Native symbolism; Begin to analyze yourself with your own strengths, weaknesses and desires; Look to your own core symbols to investigate who you are basing this on the basic shape of the circle.
Make a circular drawing of yourself using the symbols represented, or any other set of symbols that are meaningful to you using the art supplies provided. Add three or four feathers to the bottom of the peace shield, representing major accomplishments in your life that required effort. For example completing a difficult job, accomplishing a physical feat.
Pimiwatisin Wheel/Ashinabe (Ojibwa) Wheel Williams (1989; as cited in Poonwassie & Charter, 2001) prefers the Ashinabe (Ojibwa) term of the Pimawatisin Wheel, and she describes “the search for pimiwatisin” (p. 49), as “the aim and hope of living a good life on this Earth” (p.49).
374
Page 2/Medicine Wheel/The four directions …
“The four directions” – North, East, South and West. The North gives us the rocks which speaks to us of strength. The East gives us the animals which talk to us about sharing the Earth’s resources. The South represents the trees which teach us about honesty. The West gives us the grasses which teaches us about kindness. All things in this life were and are given to us by the Mother of us all – Mother Earth. Represented respectively by the colours white, red, yellow and blue; Within these colours are the four races of Man (White man, Red man, Yellow race and Black race); The four givers of life – air, food, sun and water; The four seasons – winter, spring, summer and fall; The four vices – greed, apathy, jealousy and resentment; The four moral principles – caring, vision, patience and reasoning (Poonwassie & Charter, 2001, p. 49).
The wheel can be created as a mandala, as a power shield or to depict beliefs and values.
Dahlke, R. (1992). Mandalas of the world: A meditating and painting guide. New York, NY: Sterling.
Jung, C. (1968). Man and his symbols. London: Picador.
Pincher, S. (1991). Creating mandalas: For insight, healing and self-expression. Boston: Shambhala.
375
APPENDIX Q
MASKS
I have found mask-making to facilitate the therapeutic experience for both children and adolescents but recommend that it not be used until the group is comfortable with each other. I find it helpful to include some historical background on mask-making that enhances the therapeutic experience for the individual.
Throughout history masks have held special status in many different cultures around the world. They hold universal appeal and can evoke interest, fear and reverence within many different cultures and cross culturally. Cirlot (1993) suggested that in African cultures masks are often used in religious ceremonies to portray supernatural forces and deities. They have been used in many different cultures that have oral histories to tell stories, pass down ancient fables and myths. When worn, masks transform mere mortals, give humans special powers and allows them to honour their gods (Caillois, 1958; as cited in Janzing, 1998; Cirlot, 1993; Walker, 1988).
376
Page 2/Masks/Within the …
African
Within the First Nations and native cultures, animal and bird masks hold special significance and are used to commune and honour Mother Earth and Nature. Myths and fables handed down orally designate special attributes and wisdom powers to many different animals within the animal kingdom which are meant to remind or “teach” humans how to live and manage the Earth’s resources. They also carry philosophical messages of where humans sit in a hierarchy of a native or aboriginal belief system that views humans at the bottom of the chain, rather than at the top with a multiplicity of vices that need to be curbed (Cooper, 1978).
First Nations
In Western cultures masks have a long history of association with the stage that originated with ancient Greek drama and Herculean tragedies which depicted virtues
377
Page 3/Masks/and vices … and vices (Cirlot, 1993; Cooper, 1978). In Eastern cultures masks are used on stage to tell tales of heroism and tragedy that have been handed down over centuries. The
Japanese No dramas are famous for their portrayal of demons and stock personalities that portray good and evil, heroes and heroines. Asian cultures honour the old year and the start of a new year with dragons and creatures from myth. Many masks are endowed with supernatural powers.
Greek Tragedy
Masks are also associated with traditional and religious holidays and are featured in religious and pagan festivals. Carnivale from South American cultures is associated with having fun, offering anonymity and a larger than life persona. The clown mask is a universal symbol for playing the fool and showing vulnerable qualities (Hanes, 1997).
Many individuals see masks as acting as a kind of symbolic psychological shield for the wearer that endows them with special qualities. As Dunn-Snow (2000, p. 126) stated masks have been created and used cross-culturally to tell cultural stories to
“…communicate an understanding of natural and supernatural events”and to build bridges between cultural groups.
378
Page 4/Masks/The therapeutic …
Carnivale/Clown
The Therapeutic Benefit of Masks
In art therapy, masks have been created and used as a means of nonverbal communication and to help individuals to understand themselves and their relationships with others. They are “… a means of non-verbal communication that is used to facilitate verbal communication…” and they are considered an important and effective tool in furthering psychotherapeutic work (Dunn-Snow, 2000, p. 126).
It is suggested that self-masks enhance the development of the therapeutic alliance and offer a way to address identification (self, family, culture), and issues around concealment, protection or transformation of various psychological personas (Dunn-
Snow, 2000). Creating masks can enhance a sense of personal, ethnic and cultural pride or generate an inner dialogue or “pillow talk” with the ego (Appendices Q and R).
Finished masks offer a way for individuals to “face themselves”, facilitate a transformation experience, shed an old or harmful self-image and realize a new one.
How individuals decorate masks can reveal a great deal about their defense mechanisms and can show how individuals cope with fear and anxiety. Taking on a fantasy world or creating powerful figures can suggest ways that individuals deal with feelings of power and powerlessness. It can lead to discussions around what it means
379
Page 5/Masks/to be brave or … to be brave or fearful, and what it means to be protected by (or from) feelings behind a shield as in The Wizard of Oz. Masks have become so closely associated with physical protection that they have entered a new lexicon of meaning associated with doctors, nurses, goalies, dentists, welders, baseball umpires, care drivers, fencers and astronauts.
Gillman (1978) suggested that in order to promote therapeutic communication art facilitators of the group should have first-hand experience with self-masks of life masks in an effort to understand the vulnerability and intimacy involved in the therapeutic activity. The art materials work as a catalyst and feelings can emerge quickly and sometimes violently and therapists learn that it is important to explain the process, purpose and potential outcomes of the art experiential (Dunn-Snow, 2000).
Self masks may not be appropriate for all individuals and particularly with individuals who have experienced past trauma, post traumatic stress disorder, schizophrenia or some psychological medical conditions (Janzing, 1998). It is also my experience that eating disordered clients do not deal well with having their faces covered with Plaster of Paris but can still do well with using a mold.
The Power of the Facial Mask
Faces have great psychological power because they are one of the most significant objects in the universe. Newborn infants show recognition of significant individuals in their lives from just weeks old. The primary care giver’s face is most significant but all faces and face-like configurations command attention (Dunn-Snow, 2000). In psychotherapy individual faces hold significant power because they are our mirror on the
380
Page 6/Masks/world, … world, encounter faces every day in relationships, in the media and in works of art. We also face ourselves in the mirror each day (Dunn-Snow, 2000).
Virtually every culture has “false faces” or masks and some native cultures such as the Seneca and Mohawk tribes, use the word “face” and “mask” synonymously (Fenton,
1987). The magic of the mask is that they generate a sense of mystery in that someone can hide behind it, or you can play out a fantasy or become someone (or something) else.
As Dunn-Snow and Joy-Smellie (2000) noted they can reveal, conceal or transform. In
New Guinea there are masks as tall as 20’ feet in the shape of humans or animals in an honouring process (Morris & Morris, 1993), and in China masks were worn for protection to ward of diseases such as Measles and Cholera (McNiven & McNiven).
Oriental
Previous civilizations and ancient cultures used masks to permanently record and preserve the memory of the life and death of an individual (Mack, 1994). Masks made from the molds of living people reveal a model’s state of mind as well as bone structure
(Sivin, 1986). Masks are fairly universal and appear in ancient cave drawings in the
Trois Freres” caves in France, North Africa and Spain. In the Dordogne ancient drawings show shamans or hunters (Sivin, 1986). Egyptian mummy masks date from the 22nd and
381
Page 7/Masks/21st centuries …
21st centuries B. C. In Tequixquiac, Mexico, archaeologists discovered a mask-like coyote head fashioned from Llama bones dating back to 12,000-10,000 B. C.
It is believed that mask-making has therapeutic benefit based on the recognition that from the earliest prehistoric times mask-making has been a normal human activity.
Particularly, masks have been used for transformational processes related to the spiritual realm or for healing purposes, and in special community activities, celebrations and life transitions such as birth, death marriage and puberty (Brigham, 1980). The Chokwe of
Northern Angola people use masked figures in puberty, cleansing and healing rituals where they gather up the boys and take them for ritual circumcision and instruction to the place called “the place of dying” (Mack, 1994). The animal and human masks of the
North American Indians are famous for their transformational properties related to mythical stories and symbols. Modern mask-makers use mask making to achieve similar transformational therapeutic properties.
Bali
382
Page 8/Masks/The use of …
The Use of Masks in Art Therapy
Art therapists use mask-making to help bring about a psychotherapeutic transformation from a present state to greater growth, better mental health or higher functioning which is in keeping with the historical use of masks (Dunn-Snow & Joy-
Smellie, 2000). The “magic” of the mask is also used through meaning-making to get in touch with the unconscious in an attempt to create greater wholeness.
Masks are used in a variety of therapeutic ways related to free play, role play, dramatization, to solicit a reaction from an audience, or as a way to communicate (Fryear
& Stephens, 1988; Leventhal, 1993; Wadeson, 1995). Art therapist and psychotherapists work with remade masks or create masks from wood, plaster, clay or found objects. In the 1950’s, masks were used with five boys who had a speech impediment (stuttering) and it was found that the masks made the stutter disappear (Janzing, 1998). In Europe, gestaltists use masks as a vehicle for projection or in role plays to differentiate between the physical space of “make believe” and “reality” for psychotic clients to create a safe environments to confront hallucinations (De Panafieu, 1985; as cited in Janzing, 1998).
Robert Landy (1984), a drama therapist had clients mold masks of themselves and other family members and then used them to interview family members. Fryear and
Stephens (1988) combined mask-making with performing with the masks on in a video in a group treatment as an adjunct to other therapy. Later they responded to questions from their masked selves under the theoretical assumption that the masks are symbols for interacting in a pillow –talk with the ego as a process to integrate various parts of the self
383
Page 9/Masks/that may … that may have been rejected. An interesting study was conducted by Hinz and Ragsdell
(1990) who repeated this process with bulimic women unsuccessfully. They deduced that this process was too threatening for the women and concluded that it was probably a mistake to introduce such a directed activity into an already established group.
Wadeson (1995) used cut out paper masks with elderly individuals to help them communicate with each other which helped them to have greater contact and feel less isolated. Wadeson (1978) herself wrote poetry paired with her mask-making and suggested that mask-making constitutes a “license to play”. The benefits for children and adolescents includes improving a sense of self, understanding facial features, expressing emotions and being creative plus the therapeutic benefits in story-telling. The process can also raise self-esteem by helping individuals engage in an activity that produces something that can feel proud of and something that connects therapeutically down through the ages.
Mask-making has also been used in adult growth enhancement often drawing on
Jungian theory that seeks to integrate the various parts of the personality through individuation and dealing with the concepts of “shadow” (Wadeson, 1995). Rhyne (1996) recommended the use of masks in Gestalt groups for the purposes of self-actualization through fantasies or plays by acting out self-selected roles using masks to display the personas. Duality can be expressed by making double-sided masks that can work with conflicted or contrasting psychological qualities. Alexander (1991) used the mask- making techniques with learning disabled and emotionally and behaviourally disturbed
384
Page 10/Masks/young people ... young people to depict the inner and outer selves. They used the masks as a defense mechanism to protect themselves psychologically from self-exposure.
The Individuals Who Benefit
Masks have been used therapeutically with people of all ages and degrees of psychopathology. Some therapists believe that masks and mask-making are particularly beneficial to those who need help to reveal their authentic selves and to try on new attitudes and behaviours (Janzing, 1998). Masks also help those who have had little opportunity to imaginatively play out roles in childhood (Petzold, 1992; as cited in
Janzing, 1998). It is especially beneficial to individuals who have difficulty communicating verbally (Janzing, 1998).
The use of masks may be contraindicated for those whose fragile egos might disintegrate into psychosis or for individuals suffering from borderline personalities.
There is a great deal of debate around whether individuals benefit more from concentrating on reality checking rather than going further into a fantasy world that is already over stimulated (Seigre, 1989; as cited in Janzing, 1998). Over-identification with masks may also indicate a problem for individuals with weak ego strength. Plaster masks are not recommended with individuals who have experienced trauma or abuse (Wharton,
1999).
Turner (1981) suggested that even healthy individuals can sometimes have a brief stress reaction to working with a neutral mask although they are usually replaces later with a sense of freedom and strength. The reactions may include breathing difficulties, disturbance in body perception and inner confusion. Individuals who resist mask-making
385
Page 11/Masks/may choose ...
may choose to participate by using finger masks. Wadeson (1995) suggested that masks may promote “self-expressive dramatic play” in children.
Masks are also helpful for mentally and physically handicapped children related to gaining a sense of self. Masks that are textured should be used with the visually impaired.
Hearing impaired children profit from visual and picture references. Behaviourally disturbed individuals should lean towards making masks of real animals. All of them can use masks to establish background and foreground, up and down and spatial orientation.
Mask making may not be for everyone but it can be a fun experience and stimulate the
Eureka moment.
Therapeutic interventions using masks is a powerful technique that has a lot to offer but art therapist should use the process based on historical and symbolic meanings and understanding which populations and clinical settings determine “best practice”. It is also helpful for therapists to participate in various mask-making techniques themselves to understand what it feels like, and how the processes are experienced by their clients in a passive role. It is also important for art therapists to understand when to use a specific mask technique. It should be used carefully, conscientiously and judiciously.
386
APPENDIX R
Mask-Making
Options for masks–making using clay, plaster, paper mache, wire:
Make a mask to express an emotion, select a pair of emotional opposites, quick
drawings for the spoken word (love, hate, peace, anger, family, eating disorder),
relate to emotions, relate to a situation related to an emotion;
Select an emotion and pick colours on which to build a theme mask;
Depict internal and external personas, emotions;
How you see yourself or how you think others see you;
Depict public and private selves;
Depict the good, the bad or the ugly;
Depict a side of yourself that you keep hidden;
Depict a side of yourself that you would like to portray;
Create plaster castes, half castes, top and bottom, pieces of the face;
Compare feelings at beginning and near the end of sessions, beginning and end of
process, keep a mask diary throughout the process?
Mask Materials:
Plaster of Paris (comes in bandages or in 5 or 10 lb bags in powder form (found in
local hardware stores or art stores);
Polly filla or wall stucco (comes in 5 or 10 lb bags from any hardware store);
Paper bags, or preformed human and animal molds, cut in half plastic flower pots,
balloons, paper plates, stiff paper and cardboard.
387
APPENDIX S
Art Reading/Materials List (Sample)
Three dimensional content for the art studio. Some of the artists/books and other material cited for this course.
Land Art Artists:
Abakanowicz, Magdalena: Exhibition catalogue. Museum of Contemporary Art,
Chicago, November 6, 1982 – January 2, 1983. New York, NY: Abbeville Press.
UBC Call #N7255 P62 A232.
Denes, Agnes: Barreto Ricardo, D. (1999), Sculptural Conceptualism: A new reading of
the work of Agnes Denes. Sculpture. 18C41. 16-23.
Dyck, Aganetha (1995). Exhibition catalogue. The Winnipeg Art Gallery.
Fulton, Hamish: Bird Song: A selection of walks made on the British Isles, 1970-1990.
Exhibition catalogue. Serpentine Gallery, London 1991. UBC call #NH 242 F85 A4.
Goldsworthy: Hand to earth (1990). The Henry Moore Centre for the study of sculpture,
Leeds: W. S. Manley. UBC Call # NH 242 G64 H4.
Kelly, Mary: Mary Kelly imaging desire (1995). Cambridge, Mass: The MIT Press.
Long, Richard: Stones and flies, video (1989). Arts Council of Great Britain Social
Political.
Lutz, Winifred (1998). Csaszar, T. (1998)Winifred Lutz: Perception’s nature. Sculpture,
12(3), 38-43.
Nash, David: Forms into time (1996). London: Academy Editions. ECAD call # NB 497
N37 A4.
Nils-Udo: Baume (1991). Exhibition catalogue, Aspekte Galerie, Gasteig Munchen.
Ritchie, C. (1999). Waste management. Exhibition catalogue. Art Gallery of Ontario,
388
Page 2/Reading Materials list/Sonfist ……
April 17 – July 11, 1999.
Sonfist, Alan (1997). History and the landscape, exhibition catalogue. The university of
Iowa Museum of Art , March 15 – March 15.
Tiesenhauen, Peter Von: Lebenslaufe. Exhibition catalogue, Kelowna Art Gallery,
February 21 – April 5, 1998.
Useless, Merle In Matilsky Barbara C. (1992). Fragile Ecologies: Contemporary artists’
interpretations and solutions. New York, NY: Rizzoli International Publications.
Wallace, Ian : Clayoquot protest, video (1996). Windsor Art Gallery production.
Wodiczko, Krysztof: C. Pau (1999). The prophet’s prosthesis. Sculpture, 18(4), 30-37.
Body Manipulation
Baden, Mowry: Task-oriented sculptures. Exhibition catalogue, Mercer Union, Toronto,
October 13 – November 7, 1987.
Sterbak, Jana: States of being. Exhibition catalogue. National Gallery of Canada,
Ottawa from March 8 – May 20, 1991.
Direct Casting
Whiteread, Rachel: Shedding life. Exhibition catalogue, Tate Gallery, Liverpool,
September 13 1996 – January 5, 1997. ECAD Call # NB497 W54 A5.
Ordering
Cragg, Tony: Referenced in Neff Terry, A. (Ed.), (1987). A quiet revolution: British
sculpture since 1965. New York, NY: Thames and Hudson (includes artist Richard
Deacon, Barry Flanagan, Richard Long, David Nash, Bill Woodrow).
Mach, David: David Mach (1995). London David Mach: Academy Editions. UBC Call #
389
Page 3/Art Reading Material list/Rechico …
N6797 M227 A4.
Rechico, Sandra: Sandra Rechico: Gulp (1999). Exhibition catalogue. Art Gallery of
Mississauga & Southern Alberta Art Gallery.
New Formalism
Durham, Jimmie: Jimmie Durham (1996). London: Phaidon Press
Laib, Wolfgang: A retrospective curated by Klaus Ottman and organized by the
American Federation of Arts, New York, opened at the Hirshorn Museum and
Sculpture Garden, Washington, D. D. October 26, 2000 – January 22, 2001.
Stockholder, Jessica: Jessica Stockholder (1995). London: Phaidon Press.
Performance
The Art Guys: The art guys: Think twice 1983 – 1985. Exhibition catalogue.
Contemporary Art Museum, Houston, April 8 – June 25, 1995.
Gilbert & George: Gilbert & George: The singing sculpture. London: Thames &
Hudson.
First Nations and Multicultural
Baerwaldt, W. (1997). Memories of overdevelopment: Philippine diasporia in
contemporary art. Winnipeg – Plug in Editions.
Dysart, D., & Fink, H. (Eds.). (1996). Asian women artists. Australia: An ART
AsiaPacific Book, Craftsman House.
Kubota, Nobuo: The exploration of possibility. Exhibition catalogue, Kelowna Art
Gallery, March 13 – May 2, 1999.
McMaster, G. (Ed.). (1998). Reservation: The power of place in aboriginal
390
Page 4/Art Reading Material List/Nemiroff …
contemporary art. Hull: Canadian Museum of Civilization.
Nemiroff, D., Houle, R., Townsend-Gault, C. (1992). Land spirit power: First nations
at the national gallery. Ottawa: National Gallery.
Phillips, Herbert, P. (1992). The integrative art of modern Thailand. Exhibition
catalogue, Lowie Museum.
Shimada, Yoshika: Divide and rule. Exhibition catalogue, A Space Gallery, Toronto,
February 1 – March 15, 1997. University of California at Berkley, October 19 –
December 15, 1991.
Yongwoo, Lee. (1995). Korean contemporary art. Exhibition catalogue. The Fruitmarket
Gallery, Edinburgh, Scotland, October 28 – 2 December, 1995.
Art magazines where interesting multicultural art and artists can be found: African Arts, California. Art AsiaPacific, Fine Arts Press Pty Limited, Sydney Australia, www.artasiapacific.com. Asia Art News, Hong Kong. Contemporary Visual Arts. (incorporating World art London), www.worldartmag.com.
Third Text. Third world perspectives on contemporary art & culture. Oxford.
Art Books
Alexandrian, S. (1970). Surrealist art. London: Thames and Hanes.
Birren, F. (Ed.). (1970). Itten: The elements of color. Ravensburg, Germany: Kunst der
Farbe.
Clark, K. (1978). The best of Aubrey Beardsley. New York, NJ: Doubleday.
Clark, T. J. (1999). The painting of modern life. (2nd Ed.). Princeton, New Jersey:
Princeton University Press.
Costantino, M. (2004). Klimt. (2nd Ed.). London: PRC Publishing.
391
Page 5/Art Reading Material List/Edwards …
Constantino, M. (2004). Picasso. (2nd Ed.). London: PRC Publishing.
Edwards, B. (1979). Drawing on the right side of the brain. Los Angeles: Tarcher.
Goldstein, N. (1979). Figure drawing. Englewood Cliffs, NJ: Prentice-Hall.
Kitson, M. (2004). Rembrandt. (3rd Ed.).London: Praeger.
Loshak, D. (2004). Munch. (2nd Ed.). London: PRC Publishing.
Fiell, C., & Fiell, P. (1995). Charles Rennie Mackintosh. Cologne, Germany: Taschen.
McDonald, J. (2004). Michaelangelo. (2nd Ed.). PRC Publishing.
Milner, F. (2004). Van Gogh. (2ndEd.). London: PRC Publishing.
Moorhouse, P. Dali. (2nd Ed.). London: PRC Publishing.
Phaidon (Ed.). (1969). August Rodin and his work. (7th Ed.). Northampton: Cavendish
Press.
Pickersgill, H. (1979). The impressionists. Secaucus, NJ: Albany Books.
Spender, S. Botticelli. London: Shenval Press.
Stokstad, M. Art History. (2nd Ed.). Saddle River, NJ: Prentice Hall and Abrams.
Contemporary art source book and Gerry DBA focus, great teaching site full of lesson plans, book sites and discussion groups, www.artsednet.getty.edu. Grosenick, Uta, Riemschneider, B. (Eds.). (1999). Art at the turn of the Millenium. New York: Taschen. Venezia, Mike – Series of art books in cartoon form suitable for children and adolescents (just type in the name on the internet and a whole series will come up)
Moffitt, M. (n.d.). “Night Cries”. Video.
Artists: Dali, Klimt, Michaelangelo, Munch, Picasso, Munch, Mary Cassatt, Kathy Kolwitz, Aubrey Bearsley, Mary Cassatt, Charles Rennie McIntosh, Auguste Rodin, Dante Gabriel Rosetti (Beatrice), Vincent Van Gogh, William Blake, Oscar Wilde, Auguste Rodin, etc.
392
APPENDIX T
Eating Disorder Resources
Resources:
1. Eating Disorder Research Centre Resources (2005).
Suggested Web Sites:
2. American Psychiatric Association: Practice guidelines for the treatment of patients
with eating disorders. www.psych.org/clin_res/guide.bk42301.cfm.
3. Bioethics for clinicians: A cross cultural ethics series from the Canadian medical
Association. http://www.cmaj.ca/misc/bioethics_e.shtml.
4. Eating Attitudes Test (EAT-26). Self reported test that may be scored by yourself.
www.healthplace.com/Communities/Eating_Disorders/concernedcounseling/eat/inde-
x.htm.
5. National Eating Disorders Information Centre (NEDIC). Provides information and
resources to patients, families and health-care providers. www.nedic.ca.
6. Eating Disorders Treatment Centres. http://www/mirror-mirror.org/centres.htm.
393
Eating Disorder Research Centre, Vancouver – New 2005
Videos: 1. Preventing and managing stress – Stanford Health Series, Stanford Centre for Research in Disease Prevention: a. Confident for life: Kids and body image. Disney Educational Productions. b. Opposite action: Dialectical behaviour therapy. M. Linehan. c. Dying to be thin. NOVA Mind-Altering Television. d. Beyond the looking glass: Self-esteem & body image. S. Luftman & E. Marciano. e. Body talk 2 (9-12 years). The Body Positive. f. Body talk 3 (6-9 years). The Body Positive. g. Voices of recovery. Massachussets Eating Disorder Association, Inc. h. Stupid Girls by Pink
Books: 1. Making Weight – Men’s conflicts with food, weight, shape & appearance. A. Anderson. L. Cohn, T. Holbrook. 2. The Obesity Myth: Why America’s obsession with weight is hazardous. P. Campos. 3. Chicken Soup for the Teenage Soul: 101 stories of life, love and learning. J. Canfield, M. Hansen & C. Kirberger. 4. Chicken Soup for the Teenage Soul III: More stories of life, love and learning. J. Canfield, M. Hansen & C. Kirberger. 5. Fighting invisible tigers: A stress management guide for teens. E. Hipp. 6. The Creative Journal for Teens: Making Friends with Yourself. Capacchione. 7. The teenage solutions workbook. L. Shapiro. 8. The Struggles to be Strong. True stories by teens about overcoming tough times. A. Dessta & S. Wolin. 9. Recovering from depression: A workbook for teens. M. Copeland & S. Copans. 10. Body outlaws: Young women write about body image and identity. O. Edut (Ed.). 11. Female Chauvanist Pigs by Ariel Levy
Associated Issues: 1. Changing for good: A revolutionary six-stage program for overcoming bad habits and moving your life positively forward. J. Proschaska, J. Norcross & C. DiClimente. 2. Free at last. S. Botwin. 3. Help for the hard times getting through loss. E. Hipp. 4. Knowing me, knowing you: The I-sight way to understand yourself and others. P. Espeland. 5. The seven principles for making marriage: A practical guide from the county’s foremost relationship expert. J. Gottman & N. Silver. 6. Skills training manual for treating borderline personality disorder. M. Linehan.
General: 1. Rules of “normal” eating: A common sense approach for dieters: overeaters, undereaters, emotional eaters and everyone in between! K. Koenig.
394
Page 2/Appendix T/Health food junkies …
2. Health food junkies: Anorexia Nervosa overcoming the obsession with healthful eating. S. Bratman & D. Knight.
3. Eating mindfully: How to end mindless eating and enjoy a balanced relationship with good. Albers.
Culture: 1. Mind over mood: change how you feel by changing the way you think. D. Greenberger & C. Padesky. 2. Preventing disordered eating: A manual to promote best practices for working with children, youth, families and communities. B. C. Ministry of Health Services & Ministry of Child & Families.
Treatment: 1. Body image: A handbook of theory, research and clinical practice. T. Cash, T. Pruzinsky. 2. Applied body composition assessment (2nd ed.). V. Heyward & D. Wagner. 3. Self-harm behaviour and eating disorders: Dynamics, assessment and treatment. Llevitt, Sansone & Cohn. 4. Body image: A handbook of theory, research and clinical practice. Cash & Przinsky. 5. Comparative treatments for eating disorders. L. Birmingham & P. Beaumont.
Compulsive and binge eating: 1. Overcoming the night eating syndrome. K. Allison, A. Stunkard & S. their.
Family: 1. Father hunger: Fathers, daughters and the pursuit of thinness. M. Maine. 2. Real kids come in all sizes: 10 essential lessons to build your child’s body esteem. K. Kater. 3. Parents’ guide to childhood eating disorders. M. Herrin & N. Matsumoto. 4. Surviving Ophelia: Mothers share their wisdom navigating teen years. C. Dellasega. 5. Biting the hand that starves you: Inspiring resistance to Anorexia Bulimia. E. Maisel & T. Borden. 6. All shapes and sizes: Promoting fitness and self-esteem in your overweight child. Pitman & Kaufman. 7. 101 ways to help your daughter love her body. M. Boskind-White & C. White. 8. Helping your child overcome an eating disorder: What you can do at home. B. Teachman, M. H. Schwartz, B. Gordic. 9. Dads and daughters: How to inspire, understand and support your daughter when she’s growing. Kelly.
Anorexia and Bulimia nervosa: 1. NEDIC: An introduction to food and weight problem eating disorders. Understand & overcoming an eating disorder. M. Bear.
395
Page 3/Resources List/The hunger …
2. The hunger. M. Skrypuch. 3. Walking a thin line. McNicoll. 4. Anorexia diaries: The mother and daughter’s triumph over teenage eating disorders. M. Rio & M. Rio. 5. Handbook of eating disorders and obesity. J. K. Thompson.
Interactive Resources: 1. Body image works …Promoting healthy body image through creative resource materials. (Grades 4-6 and parents). Kits available.
Resources on Order: 1. Body image, eating disorders & obesity: An integrative guide for assessment and treatment. J. K. Thompson. 2. Comparative treatment for eating disorders. Miller & Mizes (Eds.). 3. Self-harm behaviour and eating disorders. Levitt, Sansone & Cohn.
Books: Boston Women’s health Collective (1984). The new our body ourselves. New York, NY: Simon & Shuster. Brown, C., & Jasper, K. (Eds.). (1993). Consuming passions. Toronto: Secret Story Press. Carlip, H. (1995). Girl power. New York, NY: Warner. Cooke, K. (1994). Real gorgeous. New York, NY: Norton. Daris, M., Eshelman, E. R., & McKay, M. (1995). The relaxation and stress reduction workbook. Oakland: New Harbinger. Fraleigh, J., Schmelefske, J., Henderson, H., & Leora Pinhas. (1999). Why weight? A psycho-education program for teens with eating disorders and their families. Newmarket, On: Southlake Regional Health Centre. Fraser, L. (1998). Losing it: False hopes and fat profits in the diet industry. New York, NY: Plume. Freedman, R. (1998). Body love. New York, NY: Harper & Row. Friedman, S. S. (1997). When girls feel fat. New York, NY: Harper Collins. Hipp, E. (1995). Fighting invisible tigers: Stress management guide for teens. Minneapolis: Free Spirit. Pipher, M. (1994). Reviving Ophelia. New York, NYL Putman. Wolfe, N. (1991). Beauty myth. Toronto: Random House.
Magazine: Ms. Magazine: P. O. Box 50008, Boulder, Co. 80323-0008 New Moon: P. O. Box 3587, Duluth, Minnesota, USA. 55803-3587 Reluctant Hero: 189 Lonsmount Drive, Toronto, ON, M5P 2Y7 Hues: P. O. Box 7778, Ann Arbor MI> 48107 e-mail: [email protected]. Mode: P. O. Bos 54275, Boulder Co. 80323-4275.
396
Page 4/Resource List/Organizations …
Organizations: National Eating Disorder Information Centre, Toronto. Phone (416) 340-4156. Adbusters: 1243 West 7th Avenue, Vancouver, B. C. V6H 1B7 Phone: (604) 736-9401, Toll free phone: 1-800-663-1243. Fax: (604) 737-6021. Web Site: http://www.adbuster.org/adbusters/main.html.
397 This document was created with Win2PDF available at http://www.win2pdf.com. The unregistered version of Win2PDF is for evaluation or non-commercial use only. This page will not be added after purchasing Win2PDF.