Running head: ART THERAPY, TRAUMA, & COGNITIVE BEHAVIORAL THERAPY 1 The Use of Art Therapy and Cognitive Behavioral Therapy To Address Trauma Symptoms in Hospitalized Children A Paper Presented to The Faculty of the Adler Graduate School ___________________________________ In Partial Fulfillment of the Requirements for The Degree of Master of Arts in Adlerian Counseling and Psychotherapy ____________________________________ By: Anneliese Hanson September, 2013 ART THERAPY, TRAUMA, AND COGNITIVE BEHAVIORAL THERAPY 2 Abstract The experience of hospitalization can be a frightening, painful, and potentially traumatic experience for a child. When a child undergoes a hospitalization experience, there are many factors involved in that could be potentially traumatizing. Because of their limited verbal capacity, or because of the challenging content, it may be difficult for the child to accurately describe or verbalize these traumas to caregivers. Art therapy is a treatment modality that can potentially be helpful in working with hospitalized children. A review of the available literature on the use of art therapy with hospitalized children suggests two primary advantages of this modality. The first advantage is that art therapy can be used as a brief intervention, requiring as little as one session. The second advantage is that art therapy has been shown to help individuals recover from traumatic experiences through its ability to give form and meaning to thoughts and feelings. Art making can be a particularly effective intervention for reducing trauma-related problems in hospitalized children because it is both a familiar and accessible activity. It also provides an alternate path to accessing traumatic memories (as compared to standard talk therapy). The primary difficulty in researching the validity of art therapy as a trauma intervention for hospitalized children is the lack of empirical, efficacy-based studies available on this subject. In order to address this issue, the writer also looked at Cognitive Behavioral Therapy to see how it might intersect with art therapy when working with children in the hospital. Cognitive Behavioral Therapy was chosen as a treatment modality because it is currently the only empirically verified, evidence-based practice shown to have a measured improvement in trauma symptoms with children. ART THERAPY, TRAUMA, & COGNITIVE BEHAVIORAL THERAPY 3 The Use of Art Therapy and Cognitive Behavioral Therapy To Address Trauma Symptoms in Hospitalized Children There are many milestones, bumps, and hurdles in the normal development of a child from infancy through adulthood. A child’s development is, for the most part, a fun, challenging, and exciting experience that generally follows a consistent and recognizable pattern. Sometimes, however, a significant disruption in the form of an unexpected illness, injury, or accident occurs in a child’s “normal” development. These incidents are often unexpected, and can take children and their families by surprise. Medically significant illness or injury can be painful, potentially frightening, and traumatic experiences for children and their families (Banowsky-Arrington, 2007, p. 3). In the United States, pediatric trauma is the “leading cause of death after 1 year of age” (Chapman, Morabito, Ladakakos, Schreier, & Knudson, 2001). The term “pediatric trauma” refers to injuries or illnesses suffered by children and adolescents who are generally between the ages of 0-21. The types of injuries suffered are typically gunshot or stab wounds and other acts of violence, severe child abuse, or unintentional injuries such as motor vehicle accidents, falls, and burns. It can also refer to acute and chronic childhood illnesses such as asthma, sickle cell anemia, and neglect. In addition to the trauma endured by the child before he or she enters the hospital, the hospital itself can be a frightening place for a child; it is full of alien sights, smells, sounds, and it is the location where potentially painful and frightening experiences such as surgery, stitches, and other medical procedures take place. Children generally do not understand or process their hospital experience in the same way that adults do, and often experience feelings of anxiety, fear, longing for “normalcy,” and powerlessness. ART THERAPY, TRAUMA, AND COGNITIVE BEHAVIORAL THERAPY 4 Many changes have been made over the last hundred years to improve the hospital experience for children. Up until the 1960’s, many children were separated from their parents while they were in the hospital, and were often kept in open wards where they had little chance to leave their beds, let alone play or interact with their parents or other children. Markel, 2008). During this era, specialized pediatric units were a rarity, and children were often treated on adult units. During the last thirty years or so, there has been a big push to help make the hospital experience more accommodating to children by giving them specially designed pediatric units and doctors and nurses who specialize in treating children. Hospitals have also sought to improve children’s hospital experience through providing emotional and mental health support through child psychology, play therapy, and child and family life programs. Due to managed-care and tight budgeting of hospital services, non-medical care for children such as play therapy and child and family life services are not seen to be as “necessary” as the functions carried out by medical staff. This can mean that the trauma children might experience before and after being in the hospital is often not addressed during their stay. A severe illness or injury is a traumatic experience, and can have potentially detrimental effects on the mental health of the child. Being exposed to a traumatic injury can have a longer-lasting influence on a child than just the time it takes for a broken bone to heal, or for a childhood cancer to go into remission. These experiences can result in abnormal behavioral patterns, and even symptoms of Post- Traumatic Stress Disorder (PTSD). The circumstances that caused a child to be hospitalized can also be a source of trauma. Issues such as child abuse and neglect, experiencing violence, serious accidents, or chronic maltreatment can also be significant ART THERAPY, TRAUMA, & COGNITIVE BEHAVIORAL THERAPY 5 sources of trauma, and can have a “pervasive effect on the developing mind and brain…”(Tripp, 2007, p. 178). Traumatic experiences can have a negative impact on a child’s emotional and mental. “Trauma is associated with alteration in cortisol activity and reactivity that may vary in relationship to development, time, predisposition, personality, the nature of a traumatic event, and other circumstances” (Nader & Weems, 2011, p. 318). This means that traumatic experiences can actually change the structure of the brain, and that the developing brain of a child can become ‘programmed’ for stress from a very young age. Researchers have also found that there is a difference in the frontal lobe structure and function in the brains of youth with trauma histories and PTSD symptoms than children without trauma histories. These findings would make it appear that pediatric trauma is indeed an issue that needs greater attention from healthcare providers. While many improvements have been made to the healthcare experience for children, there is still much room for improvement in how trauma symptoms in pediatric patients are addressed and managed. Background of the Study The hospital is often the first time that many children who might have experienced trauma are introduced to mental-health services. The hospital is often the “first line” of mental health treatment before referrals are made to outside agencies. Since it would appear that pediatric trauma is a potentially harmful and damaging problem for children in the hospital, how might this issue be addressed? Hospitals often do not have the time or resources to quickly and efficiently assess and treat the level of psychological trauma that a child has incurred before admission or after. Children might also lack the necessary language skills or comprehension to effectively process their traumatic ART THERAPY, TRAUMA, AND COGNITIVE BEHAVIORAL THERAPY 6 experiences. A practical, effective method of working through traumatic experiences with children in a way that they can understand would be ideal. Art therapy services are a potentially good way to work with hospitalized children in the resolution of trauma. Art therapy can reach a child in a developmentally appropriate way and they can get to “deep” issues faster than traditional talk therapy can. According to Pizarro (2004), “One advantage of art therapy over writing or talk therapy is that art products (e.g., sculpture or drawings) do not require literacy or verbal fluency, yet they can convey emotion, relate a story, and stimulate verbal expression. Thus, individuals who lack the skills to communicate through writing, or are uncomfortable about verbal expression, may be encouraged to disclose by first engaging in an art project about their stressful or traumatic experience” (p. 6). There is also the idea that art and art therapy has the ability to help individuals express themselves in a deeper way than perhaps talking could. There is also the added benefit that art therapy is a strengths-based approach, and that it emphasizes potential and creativity rather than deficits. Art therapy services are usually offered through Child and Family Life departments or through play therapy