- Email: [email protected]
Working with parents in parent–child art psychotherapy
Accepted Manuscript Title: Working with Parents in Parent-Child Art Psychotherapy Author: Dafna Regev Sharon Snir PII: DOI: Reference:
S0197-4556(14)00100-2 http://dx.doi.org/doi:10.1016/j.aip.2014.10.001 AIP 1276
To appear in:
The Arts in Psychotherapy
Received date: Revised date: Accepted date:
1-1-2014 23-9-2014 3-10-2014
Please cite this article as: Regev, D., and Snir, S.,Working with Parents in Parent-Child Art Psychotherapy, The Arts in Psychotherapy (2014), http://dx.doi.org/10.1016/j.aip.2014.10.001 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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The Graduate School of Creative Art Therapies, University of Haifa, Israel Emili Sagol Creative Arts Therapies Research Center, University of Haifa, Israel
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Dafna Regeva,b and Sharon Snira,c
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Working with Parents in Parent-Child Art Psychotherapy
Department of Education and Department of Drama therapy, Tel Hai College,
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Israel.
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Correspondence concerning this article should be addressed to Dr. Dafna
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Regev, Atzmon, Israel, [email protected]
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Working with Parents in Parent-Child Art Psychotherapy Abstract
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This article is part of a broader study that addresses the consolidation of a parent-child art psychotherapy model. It outlines the advantages,
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challenges, and art interventions that can be used by art therapists when
working with parents. Twenty parent-child art therapists were interviewed
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to learn more about working with parents. The therapists' perceptions of
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parents' attitudes towards the experience of participation in therapy, encouraging parents to participate in the therapy, parental guidance, using
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art in therapy meetings, and the therapists' own parenting were characterized. The findings can help familiarize mental health therapists,
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art therapy students, and novice art therapists with the parental aspects of
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the parent-child art psychotherapy model.
Key words: Parent-child art psychotherapy; parental guidance
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Introduction
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Parent-child psychotherapy is a psychodynamic therapy approach that centers on the treatment of parent-child relations. Its objective is to treat
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disturbances in relationships in pre-latency childhood (Stern, 2005).
The main tenet of this therapeutic approach is the parental role in a
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child's emotional development and the assumption that the individual
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grows within and through relationships with others (Bowlby, 1979; Klein, 1975; Mahler, Pine & Bergman, 1975; Stern, 1995; Winnicott, 1971). The
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parent-child psychotherapy approach is based on principles of object relations theory (e.g. Bowlby, 1979; Segal, 1979; Winnicott, 1971) which
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deals with the early development of the self in its relations with others.
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There are numerous parent-child models, each of which defines the therapist's role slightly differently. However, the objective of therapy in
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them all focuses on the relationship and connections between parent and child (Harel, Kaplan, Avimeir-Patt & Ben-Aaron, 2006; Kaplan, Harel & Avimeir-Patt, 2010; McDonough, 2000; Muir, 1992). Most Israeli art therapists use the psychoanalytical-referential
orientation model in the treatment of childhood relationship disturbances, as developed by Ben-Aaron and her colleagues (Ben-Aaron, Harel, Kaplan & Patt, 2001; Harel et al., 2006; Kaplan, Harel & Avimeir-Patt, 2010). This model is mentalization-based, in which both parent and child are guided to better understand their own and others' behavior in terms of underlying mental states (e.g., thoughts, feelings, beliefs, desires, plans;
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Fonagy, Gergely & Target, 2007; Fonagy, Steele, Moran, Steele & Higgit, 1991; Fonagy & Target, 1997). The model is based on recognition of the complexity both of
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parenting and the change processes that parents undergo (Cohen, 2007), and it proposes a deeper understanding of inter-generational transferences
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of psychopathological parenting patterns and their prevention (Manzano,
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Palacio-Espesa & Zilka, 2005).
The therapy format is one weekly session in which mother-child
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and father-child alternate meetings with the same therapist. Every two to three weeks, the therapist also meets with both parents together (without
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the child) to provide them with parental guidance. During parental guidance, the therapist discusses the child and encourages the parents to
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Patt, 2010).
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observe the child's sessions with each of them (Kaplan, Harel & Avimeir-
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Parent-child art psychotherapy deriving from this model integrates artistic activity into the therapeutic setting (Gavron, 2010). Parent and child are involved in a visual creative experience that uses imagination and enables symbolic, non-verbal expression while the two engage in an artistic activity carried out jointly according to the child's developmental level (Edri, 2011; Hosea, 2006; Ponteri, 2001; Proulx, 2003; Regev, Kedem & Guttmann, 2012; Wix, 1997). The use of artistic creation as part of the therapeutic process creates inter-personal interactions, which enables therapeutic intervention in the parent-child relationship (Proulx, 2005). As part of this process, internal representations of the self, the other, and the relationship between the two are expressed symbolically,
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which constitutes a projectional space for these internal representations (Gavron, 2010). The presence of the parent in the therapy room, and parental use of art
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materials they may not have touched since their childhood constitute challenges for the therapist. The present study examined this issue by
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interviewing expert parent-child art therapists. Specifically, parent-child
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art therapists' perceptions regarding the practice of working with parents in parent-child art psychotherapy were explored. This study is part of a
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broader project that addresses the consolidation of a parent-child art psychotherapy model, through the perceptions of the therapists regarding
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their work.
This research method, which starts from art therapists' perceptions
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and aims to understand theoretical issues, is well-documented in
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psychotherapy research (Hill, Thompson, & Williams, 1997; Hill at al.,
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2005) and serves as an important tool for collecting clinical data in the field (for example, Daly & Mallinckrodt, 2007). Based on the interview findings, this article outlines the advantages, challenges, and art interventions that can be used when working with parents.
Method
Participants A total of 20 parent-child art therapists aged 36 to 61 took part in the study. 19 female art therapists and one male (see Table 1). In the first stage of the study fifteen of the 20 participants were asked to participate in a
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semi-structured interview. In the second stage the interviewees provided feedback on the findings. Responses were obtained from only 11 of the 15 Stage I interviewees; hence 5 additional art therapists were asked to
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participate in this stage. The participants were selected to take part in the study by their peers who
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defined them as experts in parent-child art psychotherapy, using the snowball
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sampling technique. All the participants had been trained in highly regarded art therapy study programs. As shown in Table 1, half of the participants worked in both
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private and public clinics and the remainder in one of the two settings; most of them referred to themselves as associated with the psychodynamic or relational object
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approach to art therapy. Sixteen of the participants were already supervisors, with 5 to 27 years' experience as art therapists and 1 to 26 years as parent-child art therapists.
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All of the art therapists gave their consent to use the interviews for research purposes
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by signing an informed consent form. The art therapists were instructed to provide examples from their treatment sessions without divulging any identifying details.
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Insert table 1 about here
Measures
The interviews were semi-structured to enable a better grasp of the participants' perceptions and collect vivid examples from their clinical experience (McCracken, 1988). The interview protocol investigated several key content areas: the place of
parent-child psychotherapy in the therapist's professional life, the kind of population he or she works with, the therapeutic setup, therapeutic contract with the patients, the objectives of therapy, the extent to which evaluations or diagnoses that involve art are used, types of interventions used, perceptions of the therapist's role, the presence and
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meaning of art work in the room, procedural events during parental instruction, success and failure in parent-child psychotherapy, challenges in therapy, and the effects of the therapist's parental self on his or her behavior.
for this purpose. Each interview lasted between one and two hours.
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Interviews with the art therapists were conducted by graduate students trained
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In this paper, which describes part of a broader study, we focused
on the advantages, challenges, and art interventions that may be used when
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working with parents according to this model, as perceived by parent-child
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art therapists. Procedure
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In the first stage, we identified art therapists who met the criteria for this study. One of us contacted potential participants by phone, explained the purpose of the study and
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asked for their verbal consent. All 15 parent-child art therapists contacted this way
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agreed to participate. Individual meetings were scheduled between each consenting participant and one of the trained interviewers at a location convenient for the
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participant-therapist. Interviews with each art therapist were conducted and recorded during a single such meeting. In the second stage, feedback was obtained via email from 11 of the 15 Stage I interviewees and from the five additional art therapists. Data Analysis
Fifteen interviews served as the basis for the data analysis. Transcripts were prepared from digital audio recordings and interview notes. Grounded theory methodology was used to analyze the data (Charmaz, 2006). In the first stage of analysis, the open coding, we read the interview transcripts and separately identified key themes and meaning units in each interview. In the second stage, the axial coding, we discussed and
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formulated the main categories, and selected a label that characterized the content of each category. We also identified themes that belonged to each of the broader categories. In the third stage, selective coding, we reviewed
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all of the interviews once more to determine the extent to which the various contents were manifested in the categories. Then, the definitions of
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the categories were fine-tuned. The categories were examined several times, until we were able to incorporate all of the information obtained
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from the interviews in them.
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Given the semi-structured nature of the interviews, certain themes were only discussed in some of the interviews, although they could
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potentially apply to all the participants. For instance, only some of the interviewees mentioned the possibility of using art based interventions for
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parental guidance. Because of the above mentioned and in order to
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understand the real frequency of each category, we have used Lincoln & Guba's (1985) methodology and contacted the participants again by email
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as well as five other parent-child art therapists. They were asked to rank, on a scale of 1 to 5, the extent to which each theme described the way they work (1=does not describe my work at all, 5=describes my work very well). The objective was to ensure that the analysis was compatible with the interviewees' interpretations and to expand the sample on which the findings were based. Using email in order to collect qualitative data becomes more and more familiar in psychotherapy research (e.g. Hill et al., 2005). In the results, the terms "most participants" or "the majority of participants"
refer to 14 or more interviewees, and the term "some of the participants" refers to 5-
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13 interviewees. Themes mentioned by fewer than five art therapists were excluded from the findings.
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Findings This section presents the five main themes that emerged from the interviews. These
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are discussed in terms of their relative frequency and examples are provided for
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purposes of illustration.
Theme 1 - Parents' Attitudes towards Participating in Parent-Child Art
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Psychotherapy
The interviews revealed several baseline attitudes concerning parental participation in
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parent-child art psychotherapy. The majority of the art therapists felt that parents came to therapy with an open attitude and a desire to improve their relationships with
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their children. A minority of art therapists addressed the variance among parents and
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agreed to this claim only in part. Many of the art therapists felt that parents' active
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participation was a significant factor both in alleviating their fears concerning criticism of their parental role and in moderating the competition that might arise between the therapist and the parent. According to most of the art therapists, parents who approach therapeutic work with a desire and a commitment to change often succeed in creating a different reality both with respect to themselves and with respect to their children. In fact, they become agents of change. Most of the interviewees mentioned the issue of change through work with parents. The importance attributed by the art therapists to having parents present in the therapy room, despite the complexity inherent in this situation, apparently stemmed from the feeling that parents can contribute to therapeutic work and be used as agents of change.
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Most of the art therapists considered that the centrality of parenting in the parents' life and their aspirations to be good parents served as a motivating force. On the other hand, most of the art therapists also emphasized the complexity inherent in
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the parental role. Entering into therapy with a distressed child is a sensitive situation in which parental capability is seemingly tested. Many of the interviews revealed that
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this situation requires a great deal of coping strength and generates a wide range of
emotions among parents, such as fear and concern for the child's wellbeing and guilt
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over their failure, as parents, to cope with the difficulty. A considerable number of art
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therapists also referred to the complexity of the parental position upon entering into parent-child art psychotherapy and the difficulty, ambivalence and fears that it poses.
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For instance one therapist stated: "They come to me for help but they're actually coming to show me that nothing helps".
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Psychotherapy
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Theme 2 – Encouraging Parents to Participate in Parent-Child Art
The first theme addressed the complexity of the parents' experience with parent-child
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art psychotherapy. Theme 2 describes the factors that help parents enter into the therapy framework and remain in it. The main factors cited by the art therapists had to do with their attitude towards the parents. Suspending judgment. All of the art therapists agreed that entering
into parent-child art psychotherapy places the parent in an exposed position vis-à-vis the therapist. They agreed that this position also becomes especially sensitive against the backdrop of the weakness and guilt that sometimes accompany the parent when seeking help. According to most of the art therapists, the parents' need to feel protected in therapy stems from this exposed position. A safe atmosphere makes it possible to develop a
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safe relationship between the participants themselves and between the participants and the therapist. The art therapists fully agreed that suspending judgment on their part encourages parents to play a role in the
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parent-child psychotherapy process: I try to tell the parents very early on that therapy is demanding of them
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too, that it's not easy, that they may feel threatened at first, that it's a bit
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uncomfortable having me look at them… but that I'm not judging them.
Listening to parents. All of the art therapists agreed that listening to
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parents helps them to continue participating in the therapy and benefit from it. Listening to parents emphasizes the importance of the information
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the parent can impart and helps the therapist understand what transpires outside of the therapy room. The therapists all agreed that by listening to
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parents, the alliance between the therapist and the parent as partners on the
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therapeutic journey is reinforced, and that listening is also very important
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as a way of containing the parents. "First of all, I listen to them. They usually really start by describing what's happening with the child at home and at school, they tell me whether they're seeing any progress, regression or deadlock".
Emphasizing the child's positive features. A considerable number of art
therapists spoke about emphasizing the child's positive features as a means of helping the parents become involved in the therapy process. According to most of the art therapists, by emphasizing the child's positive traits, the therapist conveys a positive message about the child to the parent, which can counteract opinions that were perhaps voiced by outside entities regarding the child and his/her behavior. It is also a way the parent and the therapist can praise the child and reinforce their own alliance.
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"In principle, I think the best way to involve parents is to show them how wonderful their child is. It dissipates a lot of objections. I usually try to convey the message that I'm optimistic".
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Theme 3 - Parental Guidance Theme 3 refers to the meetings with the parental dyad. This theme was divided into
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two related parts: the first deals with the therapist's encounters with the parents
concerning their interactions with their child, and the second deals with the parents'
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observations regarding their own interactions and the processes that they undergo
Interactions with the child.
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during therapy.
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Observing the parent-child sessions. All of the art therapists mentioned that the first part of any parental guidance encounter involves
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communicating observations by the therapist to the parents regarding the
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parent-child interactions that occurred during the therapy sessions: "I ask them how they felt about the session with the child. How do we do that? I
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take the artwork created in the session and then we go over it through the artwork". All of the art therapists emphasized the importance of having the parents talk about what they felt during the sessions: "I usually ask the parents to share their experiences". A considerable number of art therapists also mentioned the possibility that the therapist makes the self-evident connections: "In the parental guidance session I'll take out the file and say, for instance, 'Do you remember when I said that the girl covers the human figure in thistles, well here it is again in this drawing". According to most of the therapists, the existence of an artistic product, as evidence of the session, is significant and unique in parental guidance associated with
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parent-child art psychotherapy. The interviews reveal, and most of the art therapists concurred, that the art work serves as a mirror or documentation of the parent-child interaction and examining it helps parents see the
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change processes that are taking place over the course of therapy: "When parents have trouble seeing the changes, the mirror created by the drawing
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is very meaningful."
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Analogy between interactions in the therapy room and at home. Most of the art therapists mentioned that parental guidance sessions discuss the comparison and
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connection between events in the therapy room and similar situations at home. Most of the therapists considered that the discussion helped parents focus on recurring
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patterns of interaction and reassess their roles during such interactions: "We examine these patterns in additional situations at home. Processes that take place during the
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creation process within the dyad are usually a reflection of the relationship outside".
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Some of the art therapists described how such situations occur, and most of them
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agreed that they can be observed from a position of partnership with the parents: You say that he has tantrums and I'd like to understand what triggers them when
this happens. Perhaps if I see, we'll be able to decide together what can be done. Together we can learn and analyze, together we can do things and see things that have gone unnoticed.
Parental guidance (on a practical level). Almost all of the art therapists
mentioned the fact that they tended to help parents by giving them practical guidance regarding their interaction with their child. Most referred to the developmental features that arise in such conversations:
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I might tell them a little about what is appropriate for children of this age and what is not, for instance… Let's say, a parent who comes and tells me that the child is very dependent, very clingy, and has separation difficulties. So I might
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tell him a little about this developmental stage, what separatism and independence mean.
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Some therapists also referred to guidance in terms of what should be encouraged or
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discouraged in various interactions:
You try to raise the [parent's] awareness of features that are more functional, like
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playing with the child, spending time with him, trying to be a bridge between the child and the kindergarten teacher or the school teacher… Sometimes questions
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arise regarding all kinds of behavioral problems and issues of limits - what should and should not be done with a child.
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One of the therapist's roles is to supply the parent with a "psychological education". In
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other words, the therapist should help parents be aware of their interpretations of the
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child's behavior, and their expectations which might not be compatible with the child's age, as well as normative as opposed to deviant aspects of the child's behavior and in their relations with him/her. However, the art therapists differed in terms of how they actually conducted this intervention during therapy. A significant proportion of therapists claimed that they prepared for the meeting with the parents, and made a list of important points for discussion, from their own experience: "Before every parents' meeting I review the material, extract themes, read material that I have, and come prepared". Several therapists said that they referred parents to important resources: "I sometimes refer them to resources, email them an article, send them to the internet". Another method that was mentioned was setting a personal example for the parents: "I don't tell the parents how to behave directly; rather I try to set a personal example".
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However, most of the therapists apparently chose to set a personal example in only a very few specific cases. Parents' self-observation.
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Parents' emotional state. All of the art therapists referred to the therapeutic work that takes place during parental guidance on issues and
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representations that relate to the parents themselves. This work is based on
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the assumption, shared by all of the therapists, that the parental response
toward the child is often guided by internal working models that are based
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on early interactions between the parent and significant figures in his or her past:
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I also try to touch upon what is happening to them, where they come from, in their home, in the family, where their fears come from. For
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instance, one father had concerns about his daughter and with her hyper
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behavior - where would she end up? It touched upon a fear because she
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reminded him of his sister who had some kind of problem and he didn't want her to be like his sister.
Many art therapists emphasized both the journey that they, as therapists, share with the parents and their willingness to accompany the parents on their journey to become better acquainted with themselves: "I say that when parents, or any patients for that matter, come to therapy, they aren't coming to meet me but rather to meet themselves, and that includes their parenting, difficulties, joys, and problems." A considerable number of art therapists emphasized that even when parents choose to address sensitive issues that concern themselves, they, as therapists, will choose to orient the
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discussion toward the relevance of such issues to parenting and the parent's relationship with the child. Sometimes I won't even reveal the artwork, because a parent may come
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in with issues that can't wait and we deal with that instead, but it will always be in the context of things that happened in the therapy room.
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Other art therapists mentioned that they intervene in such a way in some
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cases, depending on the patient.
Couples issues. A significant number of art therapists mentioned
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couples issues that sometimes arise during parental guidance: "Sometimes they take the child to therapy because it's some kind of shortcut for taking
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themselves, because they themselves will not go to couples therapy, but they will take the child for therapy". Couples issues can sometimes impart
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a sense of deadlock to the process. Many therapists mentioned that they
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would choose to send couples to couples' therapy to deal with difficulties
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in the couple's relationship:
Sometimes I feel that the father is being dragged to the session to the point where he complains about his wife and orients the discussion to couples therapy, but I don't get into that. I also say to them: Those are your issues as a couple, we won't talk about them here, but let's talk about what is related to your parenting.
Almost all of the therapists agreed that they would try to get the parents to support each other in the parent-child psychotherapy process and that they stress the parents' co-parenting relationship in sessions when both parents are present. In other words, the relationship between the parents is
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intended to help their child's development: "There are mutual accusations… and then the work is actually within the couples' relationship, when we identify something fragile in each of the parents…
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each parent can help the other in difficult areas". Jealousy towards the therapist. Several art therapists mentioned
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issues of jealousy that sometimes arise during parent-child psychotherapy;
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namely jealousy of the therapist and what she represents in the
relationship, such as her ability to communicate with the child, her ability
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to contain, and so on. Most of the therapists agreed that such a situation occasionally occurs. Some of them chose to exploit the issue and work
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with it:
The rivalry is not covert, it's on the table. It's usually discussed during the
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first parental guidance session. It's there, it can't be ignored. There was a
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mother who brought cake and I asked her what was going on? She wanted
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to show me that she's a good mother. Other art therapists chose to avoid the subject: "Sometimes when a mother brings her child for therapy a little jealousy arises. I try not to go there that's not my objective".
Theme 4 - Using Art in Parental Guidance A substantial number of art therapists stated that they often use art during parental guidance as an additional way of approaching non-verbal areas of partial awareness that are otherwise difficult to tackle. In one case there were parents I had a guidance session with a month ago and I hadn't succeeded in advancing with them at all… and last week… I decided I'd
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try to have them draw. At first they were quite frightened about the idea, they didn't understand what I wanted from them, but little by little they managed to do something and I felt it was really good.
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Thus, art is used in parental guidance according to the same basic concepts of using art in therapy, as a non-verbal tool for expressing and treating internal content. A
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considerable number of art therapists noted that in addition to addressing
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subconscious areas, using art also helps parents mentalize: "As far as I'm concerned, it's just another mode of expression, if it feels uncomfortable, it can be dropped. It
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helps mentalize the relationship." In this context, the interviews revealed that art helps parents address less conscious issues and develop mental processes that help them
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observe both themselves and their relationship with their child. Some of the therapists mentioned feeling that using art during parental guidance does not suit them or the
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parents since the language of art is not a familiar or preferred alternative for self-
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expression and the parents feel a lack of control when using it. Most art therapists
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conceded that it might be appropriate for some of the parents: Parents in general have a hard time with art sometimes… most parents. The last time that they drew or worked with clay was probably in kindergarten or in elementary school. There are all kinds of reactions so if I introduce it into parental guidance it'll definitely be hard… The minute I start working with art I become less guarded, I'm already doing something else.
Several therapists reported using some art therapy techniques in their work with parents. The first was the representation of the parent, the child and their relationship. For instance:
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I ask them to draw the family engaging in some activity. And then I see the dynamics of the relations. For example, one mother drew the entire family engaging in an activity, watching television, playing, with her back to them.
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Then we really talked about this avoidance or about the degree of closeness she feels, all kinds of things that arise.
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The second technique used occasionally by some of the therapists involves suggesting
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to the parents that they draw in response to the artwork the child has created in therapy:
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Sometimes the parents don't understand what's going on in some artwork and we create a response-work. You can, for instance, make a paper window and focus
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on a certain part and later talk about why we chose this and there are a lot of variations to that, and then, through this, we try to make sense of our feelings,
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what was awakened in us. We decipher it together.
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Theme 5 - The Parenting of the Parent-Child Art Therapist
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This theme addresses the parenting experience of the parent-child art therapist. Almost all of the therapists referred to their own parenthood and mentioned how the fact that they are parents or not manifests in their work. The art therapists were divided on this issue, which is indicative of its complexity. Some of the therapists stated emphatically that it is possible to provide parent-child art psychotherapy when you are not a parent yourself, arguing that the ability to empathize and to connect to the parenting they experienced as a child helps therapists understand the parental position even without experiencing it themselves. These art therapists also gave examples of parent-child art therapists who are not parents but who, in their opinion, do very good work: "Of course someone who is not a mother
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can treat. I have my students, and one of the questions was whether they are mothers, and not one of them is a mother. And they are simply wonderful."
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Most therapists, however, stated that parenting significantly enriches the therapeutic work since it is a unique experience that is accompanied by
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new emotions that can be better understood after experiencing parenting
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oneself: "I'm sure it's an important addition. A person who's not a parent
can be a parent-child therapist, but motherhood introduces an additional
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facet to therapy and emotion". Only a minority of the therapists believed that it is crucial for the parent-child art therapist be a parent before
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providing therapy to other parents: "So I think it's very important to be a parent, a therapist, in my opinion."
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The next section presents the parent-child art therapist's parenting in greater
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detail, since it often interacts with the therapy itself.
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The therapist's parenting as enhancing empathy towards parents in therapy. A considerable number of art therapists referred to the empathy component
and claimed that the fact that they are parents themselves helps them feel greater empathy towards their patients: "I think that the fact that you're a parent somehow gives your internal dialogue another layer, so that you can be more empathetic because of similar experiences that you have gone through with your own children." The therapist's parenting experience as assisting the role of therapist. A
considerable number of art therapists stated directly that the fact that they are parents contributed to their knowledge of childrearing and helps them in their relations with parents: "As a therapist, motherhood gives me a kind of anchor. Some of the situations are familiar to me as a mother." Some of the art therapists said that in
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certain situations and after much deliberation, they share their own experience as parents with the parents they are treating: "It sometimes sets parents at ease to hear that their child is not the only one who doesn't like to shower."
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Despite the many advantages of the therapist being a parent, there are also challenges that mainly involve countertransference the therapist may feel towards the
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parents. The therapist's feelings of countertransference can lead to identification with parents undergoing treatment, to feelings of judgmentalism towards them, and
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sometimes even to jealousy.
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The therapist's parenthood as creating identification with parents undergoing treatment. Roughly half of the art therapists
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emphasized times at which they identified with parents who come to them for therapy. Others said they sometimes feel such identification:
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I think that it's easier for me to identify with the parent, and to understand
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the complexity of an interaction… not see it in a one-dimensional way
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but from both sides, I was a child and I am a parent. Some therapists claimed that such identification can also interfere with the therapeutic work: "The difficulty is the identification, a relationship that reminds me of one of my daughters. I immediately identify it and work on it in [my] supervision."
The therapist's parenthood as leading to judgmentalism vis-à-vis parents. A
small number of art therapists suggested that their own parenting might at times hinder their sense of empathy towards the parents:
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Sometimes it's also hard because you see a parent who can't really see the child. From this perspective it might sometimes be difficult. Or all kinds of things that a parent does that are sometimes not exactly what you do, you have another way.
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The therapist's parenthood as leading to jealousy towards parents undergoing therapy. About half of the art therapists mentioned that they are
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occasionally jealous of parents who come to them for therapy, with respect to
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capabilities they identify in the parent or situations the parent is exposed to during therapy:
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I'm also a mother and I too have things that arise that have to do with identifying with the parent and also sometimes a parent who really can get down and sit on
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the rug and get into the world of imagination and play… and suddenly I feel guilty for not doing it with my own children.
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Finally, although the therapist's parenting impacts her patients, the therapists' patients
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also impact her parenting. It is clear that when a therapist-parent observes parent-child
Ac ce p
situations involving others, a broad spectrum of emotions arises. Such emotions can lead to real changes in the parenting of therapists, as illustrated below. Assuming the role of parent-child therapist contributes to the
therapist's parenting. Some art therapists mentioned that working
according to the parent-child art psychotherapy model contributed to their parenting and to a deeper understanding of the importance of shared quality time and the play interaction that such time enables: The moment I started working according to the parent-child art psychotherapy model there was an effect on my eldest… Once or twice a week we shut the door to her playroom and we sit in there for half an
Page 22 of 36
hour. I realized that parents come and pay good money in order to shut themselves up in a room with their child and see him.
ip t
Discussion The findings presented here are part of a broader study that addresses the
cr
consolidation of a parent-child art psychotherapy model. Specifically, it
us
outlined the advantages, challenges, and art interventions that may be used
when working with parents according to this model, as perceived by
an
parent-child art therapists. The purpose of this paper was to begin conceptualizing the field work and link it to theoretical concepts to
M
construct a working model protocol whose effectiveness can be evaluated in the future.
d
Several main ideas emerged from the findings. First, according to
te
the therapists, most parents attend parent-child art psychotherapy with an
Ac ce p
attitude of openness and a desire to improve their relations with their children. However the therapeutic situation in this setting is not easy for parents. These results are consistent with the clinical literature showing that parents in parent-child psychotherapy often feel a wide range of emotions, such as fear and concern for the child's wellbeing and guilt over their failure as parents to cope with the difficulty (Yishai & Oren, 2006). At the beginning of therapy, most parents fear the therapist's critical eye (Kaplan, Harel & Avimeir-Patt, 2010), but most therapists feel that their presence serves as a catalyzer for change. Second, the findings suggest that there are several elements that help involve the parents in their child's therapy:
Page 23 of 36
1. Suspending judgment - When therapists suspend judgment, this helps get parents involved in the parent-child art psychotherapy process. These findings are in line with studies that have emphasized the importance of safe relations
ip t
between the child, his or her parents and the therapist when developing the reflective function (Fonagy & Target, 1997).
cr
2. Listening to parents - All of the art therapists asked the parents to take an active part in therapy. They stated it was important to listen to parents because
us
parents have important knowledge regarding their children and their parenting.
an
Listening to parents conveys a message of acceptance and containment. Bion (1967) defined containment as an event within the patient's internal world, in
M
which a part of the fantasized self is relocated (contained) within the therapist and is translated in some way into an experience that is real for the therapist.
d
Bion recommended that therapists try to come to each therapy session "with
te
no memory and with no desire". This aspiration can also help the parent-child art therapist become available for true listening to the parents, to attempt to
Ac ce p
experience the way in which the parents experience their child. In this way the therapist can learn a great deal about the child, involve the parents in the therapeutic work, and serve as a "container" for the feelings the parents bring with them, and which led them to seek treatment.
3.
Emphasizing the child's positive traits - A considerable number of art
therapists related to emphasizing the child's positive traits as a means of helping the parents achieve a better understanding of the child and be positively involved in the therapy process. This stance, which attributes importance to hope and optimism in therapy, is supported by considerable
Page 24 of 36
theoretical and research literature (e.g. Frank & Frank, 1991; Irving et al., 2004; Menninger, 1959). The findings also suggested that parental guidance may help parents
ip t
create change. The interviews revealed that the artistic product, which is produced in the parent-child session and implemented in the parental
cr
guidance session, serves as a mirror or documentation of the parent-child interaction. Examining this product helps the parents see the change
us
processes that are taking place over the course of therapy. Malchiodi
an
(2007) claimed that art, as a language composed of colors, shapes, lines and images, serves as a tool of expression in a place where words end.
M
Implementing art based interventions in parent-child art psychotherapy uses the non-verbal language of art for growth, insights, and personal
d
transformation, as well as a means for communicating thoughts, feelings,
te
and perceptions of external realities and life experiences. In parent-child psychotherapy, as in group therapy (Yalom, 1995), the pattern of
Ac ce p
relationship formed between the parent and child may be observed in the room in a way that facilitates a relatively quick connection between insights and learning in therapy and their implementation in real life, outside the therapy room.
All the art therapists noted the importance of working on parents'
internalized representations to acquire a better understanding of their child and their relationship with him/her. This is largely supported in work by object relations and relational theoreticians (Fraiberg, Adelson & Shapiro, 1975; Lieberman, Padro, Van Horn & Harris, 2005; Manzano, PalacioEspesa & Ailka, 2005). However, most of the therapists also used some
Page 25 of 36
degree of practical parental guidance such as providing information on child development. The therapists differed with respect to several issues that might be approached during parental guidance (such as working on
ip t
the parents' jealousy towards the therapist, couples issues, etc.). These issues appear important to therapy, but some of the therapists chose not to
cr
elaborate on them in order to remain focused on the relationship between
us
the parents and the child.
Fourth, most therapists mentioned a variety of ways they encouraged
an
the parents to work with the art supplies during parental guidance (when the therapist meets the parents alone). Art is used in parental guidance
M
according to the same basic concepts of using art in therapy; i.e., as a nonverbal tool for expressing and treating internal content (Betensky, 1995).
d
According to Gavron (2010), the act of creating and observing artwork
te
created drives and processes of "metaphorical insight" (Wix, 1997), which make the art meaningful, not only as describing and representing but also
Ac ce p
as enabling the acquisition of significant internal insights by the participants in this process. The therapists stated that introducing art-based interventions can be helpful in parental guidance but is not always appropriate for specific therapists or parents. The fifth and last idea deals with the parenthood of the parent-child
art therapist which can influence therapeutic work in complex ways. The debate concerning parenting and the ability of a non-parent therapist to provide therapy is not new. Emilia Perroni (2009) discussed the difference between the concepts of motherhood and motherliness, a distinction first made by psychoanalyst Helene Deutsch in 1964. Motherhood describes the
Page 26 of 36
fact that a woman is a mother whereas motherliness is an attribute that expresses an emotional attitude of a woman towards others and towards herself, and is not necessarily related to biological motherhood. Thus art
ip t
therapists who are not parents can possess traits of motherliness, which are essential to expressing appropriate emotional attitudes towards others and
cr
towards oneself. Despite the many advantages of the therapist being a parent, there are also challenges that mainly involve countertransference
us
that the therapist may feel towards the parents. The findings emphasize
an
how important it is for therapists to be aware of issues such as coping with jealousy, possible criticism and influences on the parental functioning of
M
the therapist himself.
This study has several limitations. This study was conducted in
d
Israel, and it is reasonable to assume that studies of the work of parent-
te
child art therapists in other cultural contexts would be beneficial as well. Second, although it is evident that the therapists interviewed here came
Ac ce p
from various theoretical perspectives, the model developed by Ben-Aaron and her colleagues influences the work of most parent-child art therapists in Israel. There are other parent-child models whose exploration could lead to further conceptualizations of parent-child art psychotherapy models. The present research addressed art therapists' own, self-reported perceptions regarding parent-child art psychotherapy. As authors, we did not enter the therapy rooms with the therapists. Hence there may have been differences between these accounts and the actual, objective reality. Follow-up research will continue consolidating and conceptualizing working with parents in the parent-child art psychotherapy work model
Page 27 of 36
(according to additional approaches and models as well). The effectiveness of working with parents in parent-child art psychotherapy will also be further investigated using more research-oriented means, on a broader and
cr
ip t
more heterogeneous sample.
References
us
Ben-Aaron, M., Harel, J., Kaplan, H., & Patt, R. (2001). Mother-child and
disturbances
in
childhood.
an
father-child psychotherapy: A manual for the treatment of relational Whurr
London
and
M
Philadelphia.
Publishers:
Betensky, M. G. (1995). What Do You See? - Phenomenology of Therapeutic Expression. London: Jessica Kingsley Publishers.
d
Art
te
Bion, W. (1967). Notes on memory and desire. In: E. Bott-Spillius (Ed.),
Ac ce p
Melanie Klein today (Vol. 2, pp. 17-21). London: Routledge. Bowlby, J. (1979). The making and breaking of affectional bonds. London: Tavistock.
Charmaz, K. (2006). Constructing grounded theory. London: Sage. Cohen, A. (2007). The Parenthood experience- Coping and Development. Kiryat Bialik: Ach Publisher (in Hebrew).
Daly, K. D., & Mallinckrodt, B. (2009). Experienced therapists’ approach to psychotherapy for adults with attachment avoidance or attachment anxiety.Journal of Counseling Psychology, 56(4), 549.
Page 28 of 36
Edry, A. (2011). Conjoint art work as non-verbal therapeutic communication between mother and child. Thesis submitted in partial fulfillment of the requirements for Master's degree. University of Haifa (in Hebrew).
ip t
Fonagy, P., Gergely, G. & Target, M.(2007). The parent–infant dyad and the construction of the subjective self. Journal of Child Psychology and
cr
Psychiatry, 48, (3/4), 288–328.
us
Fonagy, P. & Target, M. (1997). Attachment and Reflective function: Their
role in self organization. Development and Psychopathology, 9, 679-
an
900.
Fonagy, P., Steele, H., Moran, G., Steele, M. & Higgit, A. (1991). The
M
capacity of understanding mental states: The reflective self in parent and child and its significance for security of attachment. Infant Mental
d
Health Journal, 13, 200-217.
te
Fraiberg, S., Adelson, E. & Shapiro, V. (1975). Ghost in the nursery: a
Ac ce p
psychoanalytic approach to the problems of impaired infant-mother relationships. Journal of the American Academy of Child Psychiatry,
14, 387-421.
Frank, J. D. & Frank, J. B. (1991). Persuasion and healing. Baltimore: Johns Hopkins University Press.
Gavron, T. (2010). Psychotherapy and assessment of parent-child relationships through joint painting. In: "Parent-child Psychotherapy" (2010) Harel, J.
Pat-Avimeir, R. & Kaplan, H. (Eds). Department of
Psychology, University of
Haifa (in Hebrew).
Page 29 of 36
Harel, J., Kaplan, H., Avimeir-Patt, R. & Ben-Aaron, M. (2006). The child's active
role
in
mother-child,
father-child
psychotherapy:
A
psychodynamic approach to the treatment of relational disturbances.
ip t
Psychology and Psychotherapy: Theory, Research and Practice, 79, 23-36.
cr
Hill, C. E., Thompson, B. J., & Williams, E. N. (1997). A guide to conducting
us
consensual qualitative research. The counseling psychologist, 25(4), 517-572.
Ladany,
N.
(2005).
an
Hill, C. E., Knox, S., Thompson, B. J., Williams, E. N., Hess, S. A., & Consensual
qualitative
research:
An
M
update. Journal of Counseling Psychology, 52(2), 196. Hosea, H. (2006). “The brush’s footmarks”: Parents and infants paint together
te
Therapy, 11(2), 69-78.
d
in a small community art therapy group. International Journal of Art
Ac ce p
Irving, L. M., Snyder, C. R., Cheavens, J., Gravel, L., Hanke, J., Hilberg, P., & Nelson, N. (2004). The relationships between hope and outcomes at the
pretreatment,
beginning,
and
later
phases
of
psychotherapy. Journal of Psychotherapy Integration, 14(4), 419-443. doi:10.1037/1053-0479.14.4.419
Kaplan, H., Harel, Y. & Avimeir-Patt, R. (2010). Dyadic Therapy: An Encounter Between the Therapeutic Act and Theory. Department of Psychology, University of Haifa (in Hebrew).
Klein, M. (1975). Love guilt and reparation & other works, 1921-1945. New York, NY: Delacorte Press.
Page 30 of 36
Lieberman, A. F., Padro, E., Van Horn, P. & Harris, W. W. (2005). Angels in the Nursery: The intergenerational transmission of benevolent parental influences. Infant Mental Health Journal, 26(6), 504–520.
ip t
Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic inquiry. Newbury Park, CA: Sage Publications, Inc.
cr
Mahler, M.S., Pine, F. & Bergman, A. (1975). The Psychological birth of the
us
human infant. New York, NY: Basic Books.
Malchiodi, C. A. (2007). The art therapy sourcebook. New York, NY:
an
McGraw-Hill.
M
Manzano, G., Palacio-Espesa, P. & Zilka N. (2005). Narcissistic scenarios of parenting. The clinic for parenting consultation. Tola’at Sefarim (in
d
Hebrew).
te
McCracken, G. (1988). The long interview. Newbury Park, CA: Sage
Ac ce p
McDonough, S.C. (2000). Interaction guidance: An approach for difficult to engage families. In: C. Zeanah (Ed.), Handbook of Infant Mental
Health. New York: Guildford Press. pp. 485-493.
Menninger, K. (1959). The academic lecture on hope. American Journal of Psychiatry, 109, 481–491.
Muir, E. (1992). Watching, Waiting and Wondering: Applying psychoanalytic principles to mother-infant intervention. Infant Mental Health Journal, 13(4), 319-328.Proulx, L. (2005). Strengthening emotional ties through parent-child-dyad art therapy. Jessica Kingsley Publishers.
Page 31 of 36
Perroni, E. (2009). Motherhood: Psychoanalysis and other disciplines. Jerusalem: The Van Leer institute. Ponteri, A. K. (2001). The effect of group art therapy on depressed mothers
ip t
and their children. Art Therapy: Journal of the American Art Therapy Association, 18(3), 148-157.
cr
Proulx, L. (2003). Strengthening emotional ties through parent-child-dyad art
us
therapy. London and Philadelphia: Jessica Kingsley Publishers Ltd.
Regev. D., Kedem, D. & Guttmann, J. (2012). The effects of mothers’
an
participation in movement therapy on the emotional functioning of their school-age children in Israel. The Arts in Psychotherapy, 39, 479-
M
488.
d
Segal, H. (1979) Klein. Fontana Modern Masters.
te
Stern, D. N. (1995). The Motherhood Constellation. New-York: Basic Books.
Ac ce p
Stern, E. (2005). Post-therapy outcome check between Ben-Aaron's dyadic therapy and individual therapy patients. Thesis submitted in partial fulfillment of the requirements for Master's degree. University of Haifa (in Hebrew).
Winnicott, D.W. (1971). Playing and Reality. London, England: Tavistic Publications.
Wix, L. (1997). Picturing the relationship: An image-focused case study of a daughter and her mother. American Journal of art therapy, 35 (3), pp 74-82. Yalom, I. D. (1995). The theory and practice of group psychotherapy. Basic Books.
Page 32 of 36
Yishay, R. & Oren, D. (2006). Blocked parenthood and actualized parenthood - Parenthood as an act of creation and the contribution of dynamic parent
guidance
with
a
psychoanalytic
orientation.
Sichot
Ac ce p
te
d
M
an
us
cr
ip t
(Conversations), 20(3), 251-263 (in Hebrew).
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Research Highlights Investigates parent-child art therapists' perceptions about parental
Suggests the importance of parental involvement in therapy.
Ac ce p
te
d
M
an
us
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Emphasizes the role of art intervention in parental guidance.
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guidance
Page 34 of 36
Table
Table 1 – Therapist Demographic Information No.
Age
Gender
Setting
Theoretical
Supervisor
Seniority
orientation
Seniority in Parent-
1
42
Female
Private
Psychodynamic,
&
Phenomenologic,
Public
Narativ
Yes
15
5
2
59
Female
Public
Eclectic
Yes
14
6
3
48
Female
Private
Object relations,
Yes
14
5
&
Attachment
Yes
27
Yes
11
4
53
Female
Private
Psychodynamic,
5
39
Female
Private
Psychodynamic,
&
Object relations
Public
26
5
us
Phenomenologic
cr
Public
43
Female
Private
Eclectic
Yes
14
12
7
41
Female
Private
Psychodynamic,
Yes
10
4
&
Object relations,
Public
Family therapy
Private
Psychoanalytic,
Yes
24
17
Yes
12
10
Yes
15
10
No
5
1
Female
Relational 40
Female
Private & Public
10
40
Female
Private
Psychodynamic
ed
9
M
50
an
6
8
Psychodynamic,
ip t
child
11
36
ce pt
Object relations
Female
Public
Eclectic,
Psychoanalytic
51
Female
Public
Psychoanalytic
Yes
13
6
13
56
Female
Private
Adlerian theory,
No
9
5
&
Cognitive-
Yes
30
18
Yes
30
12
Yes
18
15
No
8
4
14
15
Ac
12
61
55
Female
Female
Public
Behavioral
Private
Developmental, Object relations, Relational
Private
Psychodynamic,
&
Phenomenologic
Public 16
55
Female
Private
Psychodynamic, Phenomenologic
17
54
Male
Private
Eclectic - Object
&
relations and self
Public
psychology.
Page 35 of 36
18
55
Female
Private
Psychodynamic,
&
Object relations
Yes
20
15
Yes
20
8
No
8
5
Public 19
50
Female
Private
Eclectic,
&
Psychoanalytic
Public Female
Public
Object relations
ce pt
ed
M
an
us
cr
ip t
42
Ac
20
Page 36 of 36
S0197-4556(14)00100-2 http://dx.doi.org/doi:10.1016/j.aip.2014.10.001 AIP 1276
To appear in:
The Arts in Psychotherapy
Received date: Revised date: Accepted date:
1-1-2014 23-9-2014 3-10-2014
Please cite this article as: Regev, D., and Snir, S.,Working with Parents in Parent-Child Art Psychotherapy, The Arts in Psychotherapy (2014), http://dx.doi.org/10.1016/j.aip.2014.10.001 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
b
c
cr
The Graduate School of Creative Art Therapies, University of Haifa, Israel Emili Sagol Creative Arts Therapies Research Center, University of Haifa, Israel
an
a
us
Dafna Regeva,b and Sharon Snira,c
ip t
Working with Parents in Parent-Child Art Psychotherapy
Department of Education and Department of Drama therapy, Tel Hai College,
d
M
Israel.
te
Correspondence concerning this article should be addressed to Dr. Dafna
Ac ce p
Regev, Atzmon, Israel, [email protected]
Page 1 of 36
Working with Parents in Parent-Child Art Psychotherapy Abstract
ip t
This article is part of a broader study that addresses the consolidation of a parent-child art psychotherapy model. It outlines the advantages,
cr
challenges, and art interventions that can be used by art therapists when
working with parents. Twenty parent-child art therapists were interviewed
us
to learn more about working with parents. The therapists' perceptions of
an
parents' attitudes towards the experience of participation in therapy, encouraging parents to participate in the therapy, parental guidance, using
M
art in therapy meetings, and the therapists' own parenting were characterized. The findings can help familiarize mental health therapists,
d
art therapy students, and novice art therapists with the parental aspects of
Ac ce p
te
the parent-child art psychotherapy model.
Key words: Parent-child art psychotherapy; parental guidance
Page 2 of 36
Introduction
ip t
Parent-child psychotherapy is a psychodynamic therapy approach that centers on the treatment of parent-child relations. Its objective is to treat
cr
disturbances in relationships in pre-latency childhood (Stern, 2005).
The main tenet of this therapeutic approach is the parental role in a
us
child's emotional development and the assumption that the individual
an
grows within and through relationships with others (Bowlby, 1979; Klein, 1975; Mahler, Pine & Bergman, 1975; Stern, 1995; Winnicott, 1971). The
M
parent-child psychotherapy approach is based on principles of object relations theory (e.g. Bowlby, 1979; Segal, 1979; Winnicott, 1971) which
d
deals with the early development of the self in its relations with others.
te
There are numerous parent-child models, each of which defines the therapist's role slightly differently. However, the objective of therapy in
Ac ce p
them all focuses on the relationship and connections between parent and child (Harel, Kaplan, Avimeir-Patt & Ben-Aaron, 2006; Kaplan, Harel & Avimeir-Patt, 2010; McDonough, 2000; Muir, 1992). Most Israeli art therapists use the psychoanalytical-referential
orientation model in the treatment of childhood relationship disturbances, as developed by Ben-Aaron and her colleagues (Ben-Aaron, Harel, Kaplan & Patt, 2001; Harel et al., 2006; Kaplan, Harel & Avimeir-Patt, 2010). This model is mentalization-based, in which both parent and child are guided to better understand their own and others' behavior in terms of underlying mental states (e.g., thoughts, feelings, beliefs, desires, plans;
Page 3 of 36
Fonagy, Gergely & Target, 2007; Fonagy, Steele, Moran, Steele & Higgit, 1991; Fonagy & Target, 1997). The model is based on recognition of the complexity both of
ip t
parenting and the change processes that parents undergo (Cohen, 2007), and it proposes a deeper understanding of inter-generational transferences
cr
of psychopathological parenting patterns and their prevention (Manzano,
us
Palacio-Espesa & Zilka, 2005).
The therapy format is one weekly session in which mother-child
an
and father-child alternate meetings with the same therapist. Every two to three weeks, the therapist also meets with both parents together (without
M
the child) to provide them with parental guidance. During parental guidance, the therapist discusses the child and encourages the parents to
te
Patt, 2010).
d
observe the child's sessions with each of them (Kaplan, Harel & Avimeir-
Ac ce p
Parent-child art psychotherapy deriving from this model integrates artistic activity into the therapeutic setting (Gavron, 2010). Parent and child are involved in a visual creative experience that uses imagination and enables symbolic, non-verbal expression while the two engage in an artistic activity carried out jointly according to the child's developmental level (Edri, 2011; Hosea, 2006; Ponteri, 2001; Proulx, 2003; Regev, Kedem & Guttmann, 2012; Wix, 1997). The use of artistic creation as part of the therapeutic process creates inter-personal interactions, which enables therapeutic intervention in the parent-child relationship (Proulx, 2005). As part of this process, internal representations of the self, the other, and the relationship between the two are expressed symbolically,
Page 4 of 36
which constitutes a projectional space for these internal representations (Gavron, 2010). The presence of the parent in the therapy room, and parental use of art
ip t
materials they may not have touched since their childhood constitute challenges for the therapist. The present study examined this issue by
cr
interviewing expert parent-child art therapists. Specifically, parent-child
us
art therapists' perceptions regarding the practice of working with parents in parent-child art psychotherapy were explored. This study is part of a
an
broader project that addresses the consolidation of a parent-child art psychotherapy model, through the perceptions of the therapists regarding
M
their work.
This research method, which starts from art therapists' perceptions
d
and aims to understand theoretical issues, is well-documented in
te
psychotherapy research (Hill, Thompson, & Williams, 1997; Hill at al.,
Ac ce p
2005) and serves as an important tool for collecting clinical data in the field (for example, Daly & Mallinckrodt, 2007). Based on the interview findings, this article outlines the advantages, challenges, and art interventions that can be used when working with parents.
Method
Participants A total of 20 parent-child art therapists aged 36 to 61 took part in the study. 19 female art therapists and one male (see Table 1). In the first stage of the study fifteen of the 20 participants were asked to participate in a
Page 5 of 36
semi-structured interview. In the second stage the interviewees provided feedback on the findings. Responses were obtained from only 11 of the 15 Stage I interviewees; hence 5 additional art therapists were asked to
ip t
participate in this stage. The participants were selected to take part in the study by their peers who
cr
defined them as experts in parent-child art psychotherapy, using the snowball
us
sampling technique. All the participants had been trained in highly regarded art therapy study programs. As shown in Table 1, half of the participants worked in both
an
private and public clinics and the remainder in one of the two settings; most of them referred to themselves as associated with the psychodynamic or relational object
M
approach to art therapy. Sixteen of the participants were already supervisors, with 5 to 27 years' experience as art therapists and 1 to 26 years as parent-child art therapists.
d
All of the art therapists gave their consent to use the interviews for research purposes
te
by signing an informed consent form. The art therapists were instructed to provide examples from their treatment sessions without divulging any identifying details.
Ac ce p
Insert table 1 about here
Measures
The interviews were semi-structured to enable a better grasp of the participants' perceptions and collect vivid examples from their clinical experience (McCracken, 1988). The interview protocol investigated several key content areas: the place of
parent-child psychotherapy in the therapist's professional life, the kind of population he or she works with, the therapeutic setup, therapeutic contract with the patients, the objectives of therapy, the extent to which evaluations or diagnoses that involve art are used, types of interventions used, perceptions of the therapist's role, the presence and
Page 6 of 36
meaning of art work in the room, procedural events during parental instruction, success and failure in parent-child psychotherapy, challenges in therapy, and the effects of the therapist's parental self on his or her behavior.
for this purpose. Each interview lasted between one and two hours.
ip t
Interviews with the art therapists were conducted by graduate students trained
cr
In this paper, which describes part of a broader study, we focused
on the advantages, challenges, and art interventions that may be used when
us
working with parents according to this model, as perceived by parent-child
an
art therapists. Procedure
M
In the first stage, we identified art therapists who met the criteria for this study. One of us contacted potential participants by phone, explained the purpose of the study and
d
asked for their verbal consent. All 15 parent-child art therapists contacted this way
te
agreed to participate. Individual meetings were scheduled between each consenting participant and one of the trained interviewers at a location convenient for the
Ac ce p
participant-therapist. Interviews with each art therapist were conducted and recorded during a single such meeting. In the second stage, feedback was obtained via email from 11 of the 15 Stage I interviewees and from the five additional art therapists. Data Analysis
Fifteen interviews served as the basis for the data analysis. Transcripts were prepared from digital audio recordings and interview notes. Grounded theory methodology was used to analyze the data (Charmaz, 2006). In the first stage of analysis, the open coding, we read the interview transcripts and separately identified key themes and meaning units in each interview. In the second stage, the axial coding, we discussed and
Page 7 of 36
formulated the main categories, and selected a label that characterized the content of each category. We also identified themes that belonged to each of the broader categories. In the third stage, selective coding, we reviewed
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all of the interviews once more to determine the extent to which the various contents were manifested in the categories. Then, the definitions of
cr
the categories were fine-tuned. The categories were examined several times, until we were able to incorporate all of the information obtained
us
from the interviews in them.
an
Given the semi-structured nature of the interviews, certain themes were only discussed in some of the interviews, although they could
M
potentially apply to all the participants. For instance, only some of the interviewees mentioned the possibility of using art based interventions for
d
parental guidance. Because of the above mentioned and in order to
te
understand the real frequency of each category, we have used Lincoln & Guba's (1985) methodology and contacted the participants again by email
Ac ce p
as well as five other parent-child art therapists. They were asked to rank, on a scale of 1 to 5, the extent to which each theme described the way they work (1=does not describe my work at all, 5=describes my work very well). The objective was to ensure that the analysis was compatible with the interviewees' interpretations and to expand the sample on which the findings were based. Using email in order to collect qualitative data becomes more and more familiar in psychotherapy research (e.g. Hill et al., 2005). In the results, the terms "most participants" or "the majority of participants"
refer to 14 or more interviewees, and the term "some of the participants" refers to 5-
Page 8 of 36
13 interviewees. Themes mentioned by fewer than five art therapists were excluded from the findings.
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Findings This section presents the five main themes that emerged from the interviews. These
cr
are discussed in terms of their relative frequency and examples are provided for
us
purposes of illustration.
Theme 1 - Parents' Attitudes towards Participating in Parent-Child Art
an
Psychotherapy
The interviews revealed several baseline attitudes concerning parental participation in
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parent-child art psychotherapy. The majority of the art therapists felt that parents came to therapy with an open attitude and a desire to improve their relationships with
d
their children. A minority of art therapists addressed the variance among parents and
te
agreed to this claim only in part. Many of the art therapists felt that parents' active
Ac ce p
participation was a significant factor both in alleviating their fears concerning criticism of their parental role and in moderating the competition that might arise between the therapist and the parent. According to most of the art therapists, parents who approach therapeutic work with a desire and a commitment to change often succeed in creating a different reality both with respect to themselves and with respect to their children. In fact, they become agents of change. Most of the interviewees mentioned the issue of change through work with parents. The importance attributed by the art therapists to having parents present in the therapy room, despite the complexity inherent in this situation, apparently stemmed from the feeling that parents can contribute to therapeutic work and be used as agents of change.
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Most of the art therapists considered that the centrality of parenting in the parents' life and their aspirations to be good parents served as a motivating force. On the other hand, most of the art therapists also emphasized the complexity inherent in
ip t
the parental role. Entering into therapy with a distressed child is a sensitive situation in which parental capability is seemingly tested. Many of the interviews revealed that
cr
this situation requires a great deal of coping strength and generates a wide range of
emotions among parents, such as fear and concern for the child's wellbeing and guilt
us
over their failure, as parents, to cope with the difficulty. A considerable number of art
an
therapists also referred to the complexity of the parental position upon entering into parent-child art psychotherapy and the difficulty, ambivalence and fears that it poses.
M
For instance one therapist stated: "They come to me for help but they're actually coming to show me that nothing helps".
te
Psychotherapy
d
Theme 2 – Encouraging Parents to Participate in Parent-Child Art
The first theme addressed the complexity of the parents' experience with parent-child
Ac ce p
art psychotherapy. Theme 2 describes the factors that help parents enter into the therapy framework and remain in it. The main factors cited by the art therapists had to do with their attitude towards the parents. Suspending judgment. All of the art therapists agreed that entering
into parent-child art psychotherapy places the parent in an exposed position vis-à-vis the therapist. They agreed that this position also becomes especially sensitive against the backdrop of the weakness and guilt that sometimes accompany the parent when seeking help. According to most of the art therapists, the parents' need to feel protected in therapy stems from this exposed position. A safe atmosphere makes it possible to develop a
Page 10 of 36
safe relationship between the participants themselves and between the participants and the therapist. The art therapists fully agreed that suspending judgment on their part encourages parents to play a role in the
ip t
parent-child psychotherapy process: I try to tell the parents very early on that therapy is demanding of them
cr
too, that it's not easy, that they may feel threatened at first, that it's a bit
us
uncomfortable having me look at them… but that I'm not judging them.
Listening to parents. All of the art therapists agreed that listening to
an
parents helps them to continue participating in the therapy and benefit from it. Listening to parents emphasizes the importance of the information
M
the parent can impart and helps the therapist understand what transpires outside of the therapy room. The therapists all agreed that by listening to
d
parents, the alliance between the therapist and the parent as partners on the
te
therapeutic journey is reinforced, and that listening is also very important
Ac ce p
as a way of containing the parents. "First of all, I listen to them. They usually really start by describing what's happening with the child at home and at school, they tell me whether they're seeing any progress, regression or deadlock".
Emphasizing the child's positive features. A considerable number of art
therapists spoke about emphasizing the child's positive features as a means of helping the parents become involved in the therapy process. According to most of the art therapists, by emphasizing the child's positive traits, the therapist conveys a positive message about the child to the parent, which can counteract opinions that were perhaps voiced by outside entities regarding the child and his/her behavior. It is also a way the parent and the therapist can praise the child and reinforce their own alliance.
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"In principle, I think the best way to involve parents is to show them how wonderful their child is. It dissipates a lot of objections. I usually try to convey the message that I'm optimistic".
ip t
Theme 3 - Parental Guidance Theme 3 refers to the meetings with the parental dyad. This theme was divided into
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two related parts: the first deals with the therapist's encounters with the parents
concerning their interactions with their child, and the second deals with the parents'
us
observations regarding their own interactions and the processes that they undergo
Interactions with the child.
an
during therapy.
M
Observing the parent-child sessions. All of the art therapists mentioned that the first part of any parental guidance encounter involves
d
communicating observations by the therapist to the parents regarding the
te
parent-child interactions that occurred during the therapy sessions: "I ask them how they felt about the session with the child. How do we do that? I
Ac ce p
take the artwork created in the session and then we go over it through the artwork". All of the art therapists emphasized the importance of having the parents talk about what they felt during the sessions: "I usually ask the parents to share their experiences". A considerable number of art therapists also mentioned the possibility that the therapist makes the self-evident connections: "In the parental guidance session I'll take out the file and say, for instance, 'Do you remember when I said that the girl covers the human figure in thistles, well here it is again in this drawing". According to most of the therapists, the existence of an artistic product, as evidence of the session, is significant and unique in parental guidance associated with
Page 12 of 36
parent-child art psychotherapy. The interviews reveal, and most of the art therapists concurred, that the art work serves as a mirror or documentation of the parent-child interaction and examining it helps parents see the
ip t
change processes that are taking place over the course of therapy: "When parents have trouble seeing the changes, the mirror created by the drawing
cr
is very meaningful."
us
Analogy between interactions in the therapy room and at home. Most of the art therapists mentioned that parental guidance sessions discuss the comparison and
an
connection between events in the therapy room and similar situations at home. Most of the therapists considered that the discussion helped parents focus on recurring
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patterns of interaction and reassess their roles during such interactions: "We examine these patterns in additional situations at home. Processes that take place during the
d
creation process within the dyad are usually a reflection of the relationship outside".
te
Some of the art therapists described how such situations occur, and most of them
Ac ce p
agreed that they can be observed from a position of partnership with the parents: You say that he has tantrums and I'd like to understand what triggers them when
this happens. Perhaps if I see, we'll be able to decide together what can be done. Together we can learn and analyze, together we can do things and see things that have gone unnoticed.
Parental guidance (on a practical level). Almost all of the art therapists
mentioned the fact that they tended to help parents by giving them practical guidance regarding their interaction with their child. Most referred to the developmental features that arise in such conversations:
Page 13 of 36
I might tell them a little about what is appropriate for children of this age and what is not, for instance… Let's say, a parent who comes and tells me that the child is very dependent, very clingy, and has separation difficulties. So I might
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tell him a little about this developmental stage, what separatism and independence mean.
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Some therapists also referred to guidance in terms of what should be encouraged or
us
discouraged in various interactions:
You try to raise the [parent's] awareness of features that are more functional, like
an
playing with the child, spending time with him, trying to be a bridge between the child and the kindergarten teacher or the school teacher… Sometimes questions
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arise regarding all kinds of behavioral problems and issues of limits - what should and should not be done with a child.
d
One of the therapist's roles is to supply the parent with a "psychological education". In
te
other words, the therapist should help parents be aware of their interpretations of the
Ac ce p
child's behavior, and their expectations which might not be compatible with the child's age, as well as normative as opposed to deviant aspects of the child's behavior and in their relations with him/her. However, the art therapists differed in terms of how they actually conducted this intervention during therapy. A significant proportion of therapists claimed that they prepared for the meeting with the parents, and made a list of important points for discussion, from their own experience: "Before every parents' meeting I review the material, extract themes, read material that I have, and come prepared". Several therapists said that they referred parents to important resources: "I sometimes refer them to resources, email them an article, send them to the internet". Another method that was mentioned was setting a personal example for the parents: "I don't tell the parents how to behave directly; rather I try to set a personal example".
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However, most of the therapists apparently chose to set a personal example in only a very few specific cases. Parents' self-observation.
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Parents' emotional state. All of the art therapists referred to the therapeutic work that takes place during parental guidance on issues and
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representations that relate to the parents themselves. This work is based on
us
the assumption, shared by all of the therapists, that the parental response
toward the child is often guided by internal working models that are based
an
on early interactions between the parent and significant figures in his or her past:
M
I also try to touch upon what is happening to them, where they come from, in their home, in the family, where their fears come from. For
d
instance, one father had concerns about his daughter and with her hyper
te
behavior - where would she end up? It touched upon a fear because she
Ac ce p
reminded him of his sister who had some kind of problem and he didn't want her to be like his sister.
Many art therapists emphasized both the journey that they, as therapists, share with the parents and their willingness to accompany the parents on their journey to become better acquainted with themselves: "I say that when parents, or any patients for that matter, come to therapy, they aren't coming to meet me but rather to meet themselves, and that includes their parenting, difficulties, joys, and problems." A considerable number of art therapists emphasized that even when parents choose to address sensitive issues that concern themselves, they, as therapists, will choose to orient the
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discussion toward the relevance of such issues to parenting and the parent's relationship with the child. Sometimes I won't even reveal the artwork, because a parent may come
ip t
in with issues that can't wait and we deal with that instead, but it will always be in the context of things that happened in the therapy room.
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Other art therapists mentioned that they intervene in such a way in some
us
cases, depending on the patient.
Couples issues. A significant number of art therapists mentioned
an
couples issues that sometimes arise during parental guidance: "Sometimes they take the child to therapy because it's some kind of shortcut for taking
M
themselves, because they themselves will not go to couples therapy, but they will take the child for therapy". Couples issues can sometimes impart
d
a sense of deadlock to the process. Many therapists mentioned that they
te
would choose to send couples to couples' therapy to deal with difficulties
Ac ce p
in the couple's relationship:
Sometimes I feel that the father is being dragged to the session to the point where he complains about his wife and orients the discussion to couples therapy, but I don't get into that. I also say to them: Those are your issues as a couple, we won't talk about them here, but let's talk about what is related to your parenting.
Almost all of the therapists agreed that they would try to get the parents to support each other in the parent-child psychotherapy process and that they stress the parents' co-parenting relationship in sessions when both parents are present. In other words, the relationship between the parents is
Page 16 of 36
intended to help their child's development: "There are mutual accusations… and then the work is actually within the couples' relationship, when we identify something fragile in each of the parents…
ip t
each parent can help the other in difficult areas". Jealousy towards the therapist. Several art therapists mentioned
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issues of jealousy that sometimes arise during parent-child psychotherapy;
us
namely jealousy of the therapist and what she represents in the
relationship, such as her ability to communicate with the child, her ability
an
to contain, and so on. Most of the therapists agreed that such a situation occasionally occurs. Some of them chose to exploit the issue and work
M
with it:
The rivalry is not covert, it's on the table. It's usually discussed during the
d
first parental guidance session. It's there, it can't be ignored. There was a
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mother who brought cake and I asked her what was going on? She wanted
Ac ce p
to show me that she's a good mother. Other art therapists chose to avoid the subject: "Sometimes when a mother brings her child for therapy a little jealousy arises. I try not to go there that's not my objective".
Theme 4 - Using Art in Parental Guidance A substantial number of art therapists stated that they often use art during parental guidance as an additional way of approaching non-verbal areas of partial awareness that are otherwise difficult to tackle. In one case there were parents I had a guidance session with a month ago and I hadn't succeeded in advancing with them at all… and last week… I decided I'd
Page 17 of 36
try to have them draw. At first they were quite frightened about the idea, they didn't understand what I wanted from them, but little by little they managed to do something and I felt it was really good.
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Thus, art is used in parental guidance according to the same basic concepts of using art in therapy, as a non-verbal tool for expressing and treating internal content. A
cr
considerable number of art therapists noted that in addition to addressing
us
subconscious areas, using art also helps parents mentalize: "As far as I'm concerned, it's just another mode of expression, if it feels uncomfortable, it can be dropped. It
an
helps mentalize the relationship." In this context, the interviews revealed that art helps parents address less conscious issues and develop mental processes that help them
M
observe both themselves and their relationship with their child. Some of the therapists mentioned feeling that using art during parental guidance does not suit them or the
d
parents since the language of art is not a familiar or preferred alternative for self-
te
expression and the parents feel a lack of control when using it. Most art therapists
Ac ce p
conceded that it might be appropriate for some of the parents: Parents in general have a hard time with art sometimes… most parents. The last time that they drew or worked with clay was probably in kindergarten or in elementary school. There are all kinds of reactions so if I introduce it into parental guidance it'll definitely be hard… The minute I start working with art I become less guarded, I'm already doing something else.
Several therapists reported using some art therapy techniques in their work with parents. The first was the representation of the parent, the child and their relationship. For instance:
Page 18 of 36
I ask them to draw the family engaging in some activity. And then I see the dynamics of the relations. For example, one mother drew the entire family engaging in an activity, watching television, playing, with her back to them.
ip t
Then we really talked about this avoidance or about the degree of closeness she feels, all kinds of things that arise.
cr
The second technique used occasionally by some of the therapists involves suggesting
us
to the parents that they draw in response to the artwork the child has created in therapy:
an
Sometimes the parents don't understand what's going on in some artwork and we create a response-work. You can, for instance, make a paper window and focus
M
on a certain part and later talk about why we chose this and there are a lot of variations to that, and then, through this, we try to make sense of our feelings,
d
what was awakened in us. We decipher it together.
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Theme 5 - The Parenting of the Parent-Child Art Therapist
Ac ce p
This theme addresses the parenting experience of the parent-child art therapist. Almost all of the therapists referred to their own parenthood and mentioned how the fact that they are parents or not manifests in their work. The art therapists were divided on this issue, which is indicative of its complexity. Some of the therapists stated emphatically that it is possible to provide parent-child art psychotherapy when you are not a parent yourself, arguing that the ability to empathize and to connect to the parenting they experienced as a child helps therapists understand the parental position even without experiencing it themselves. These art therapists also gave examples of parent-child art therapists who are not parents but who, in their opinion, do very good work: "Of course someone who is not a mother
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can treat. I have my students, and one of the questions was whether they are mothers, and not one of them is a mother. And they are simply wonderful."
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Most therapists, however, stated that parenting significantly enriches the therapeutic work since it is a unique experience that is accompanied by
cr
new emotions that can be better understood after experiencing parenting
us
oneself: "I'm sure it's an important addition. A person who's not a parent
can be a parent-child therapist, but motherhood introduces an additional
an
facet to therapy and emotion". Only a minority of the therapists believed that it is crucial for the parent-child art therapist be a parent before
M
providing therapy to other parents: "So I think it's very important to be a parent, a therapist, in my opinion."
d
The next section presents the parent-child art therapist's parenting in greater
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detail, since it often interacts with the therapy itself.
Ac ce p
The therapist's parenting as enhancing empathy towards parents in therapy. A considerable number of art therapists referred to the empathy component
and claimed that the fact that they are parents themselves helps them feel greater empathy towards their patients: "I think that the fact that you're a parent somehow gives your internal dialogue another layer, so that you can be more empathetic because of similar experiences that you have gone through with your own children." The therapist's parenting experience as assisting the role of therapist. A
considerable number of art therapists stated directly that the fact that they are parents contributed to their knowledge of childrearing and helps them in their relations with parents: "As a therapist, motherhood gives me a kind of anchor. Some of the situations are familiar to me as a mother." Some of the art therapists said that in
Page 20 of 36
certain situations and after much deliberation, they share their own experience as parents with the parents they are treating: "It sometimes sets parents at ease to hear that their child is not the only one who doesn't like to shower."
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Despite the many advantages of the therapist being a parent, there are also challenges that mainly involve countertransference the therapist may feel towards the
cr
parents. The therapist's feelings of countertransference can lead to identification with parents undergoing treatment, to feelings of judgmentalism towards them, and
us
sometimes even to jealousy.
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The therapist's parenthood as creating identification with parents undergoing treatment. Roughly half of the art therapists
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emphasized times at which they identified with parents who come to them for therapy. Others said they sometimes feel such identification:
d
I think that it's easier for me to identify with the parent, and to understand
te
the complexity of an interaction… not see it in a one-dimensional way
Ac ce p
but from both sides, I was a child and I am a parent. Some therapists claimed that such identification can also interfere with the therapeutic work: "The difficulty is the identification, a relationship that reminds me of one of my daughters. I immediately identify it and work on it in [my] supervision."
The therapist's parenthood as leading to judgmentalism vis-à-vis parents. A
small number of art therapists suggested that their own parenting might at times hinder their sense of empathy towards the parents:
Page 21 of 36
Sometimes it's also hard because you see a parent who can't really see the child. From this perspective it might sometimes be difficult. Or all kinds of things that a parent does that are sometimes not exactly what you do, you have another way.
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The therapist's parenthood as leading to jealousy towards parents undergoing therapy. About half of the art therapists mentioned that they are
cr
occasionally jealous of parents who come to them for therapy, with respect to
us
capabilities they identify in the parent or situations the parent is exposed to during therapy:
an
I'm also a mother and I too have things that arise that have to do with identifying with the parent and also sometimes a parent who really can get down and sit on
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the rug and get into the world of imagination and play… and suddenly I feel guilty for not doing it with my own children.
d
Finally, although the therapist's parenting impacts her patients, the therapists' patients
te
also impact her parenting. It is clear that when a therapist-parent observes parent-child
Ac ce p
situations involving others, a broad spectrum of emotions arises. Such emotions can lead to real changes in the parenting of therapists, as illustrated below. Assuming the role of parent-child therapist contributes to the
therapist's parenting. Some art therapists mentioned that working
according to the parent-child art psychotherapy model contributed to their parenting and to a deeper understanding of the importance of shared quality time and the play interaction that such time enables: The moment I started working according to the parent-child art psychotherapy model there was an effect on my eldest… Once or twice a week we shut the door to her playroom and we sit in there for half an
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hour. I realized that parents come and pay good money in order to shut themselves up in a room with their child and see him.
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Discussion The findings presented here are part of a broader study that addresses the
cr
consolidation of a parent-child art psychotherapy model. Specifically, it
us
outlined the advantages, challenges, and art interventions that may be used
when working with parents according to this model, as perceived by
an
parent-child art therapists. The purpose of this paper was to begin conceptualizing the field work and link it to theoretical concepts to
M
construct a working model protocol whose effectiveness can be evaluated in the future.
d
Several main ideas emerged from the findings. First, according to
te
the therapists, most parents attend parent-child art psychotherapy with an
Ac ce p
attitude of openness and a desire to improve their relations with their children. However the therapeutic situation in this setting is not easy for parents. These results are consistent with the clinical literature showing that parents in parent-child psychotherapy often feel a wide range of emotions, such as fear and concern for the child's wellbeing and guilt over their failure as parents to cope with the difficulty (Yishai & Oren, 2006). At the beginning of therapy, most parents fear the therapist's critical eye (Kaplan, Harel & Avimeir-Patt, 2010), but most therapists feel that their presence serves as a catalyzer for change. Second, the findings suggest that there are several elements that help involve the parents in their child's therapy:
Page 23 of 36
1. Suspending judgment - When therapists suspend judgment, this helps get parents involved in the parent-child art psychotherapy process. These findings are in line with studies that have emphasized the importance of safe relations
ip t
between the child, his or her parents and the therapist when developing the reflective function (Fonagy & Target, 1997).
cr
2. Listening to parents - All of the art therapists asked the parents to take an active part in therapy. They stated it was important to listen to parents because
us
parents have important knowledge regarding their children and their parenting.
an
Listening to parents conveys a message of acceptance and containment. Bion (1967) defined containment as an event within the patient's internal world, in
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which a part of the fantasized self is relocated (contained) within the therapist and is translated in some way into an experience that is real for the therapist.
d
Bion recommended that therapists try to come to each therapy session "with
te
no memory and with no desire". This aspiration can also help the parent-child art therapist become available for true listening to the parents, to attempt to
Ac ce p
experience the way in which the parents experience their child. In this way the therapist can learn a great deal about the child, involve the parents in the therapeutic work, and serve as a "container" for the feelings the parents bring with them, and which led them to seek treatment.
3.
Emphasizing the child's positive traits - A considerable number of art
therapists related to emphasizing the child's positive traits as a means of helping the parents achieve a better understanding of the child and be positively involved in the therapy process. This stance, which attributes importance to hope and optimism in therapy, is supported by considerable
Page 24 of 36
theoretical and research literature (e.g. Frank & Frank, 1991; Irving et al., 2004; Menninger, 1959). The findings also suggested that parental guidance may help parents
ip t
create change. The interviews revealed that the artistic product, which is produced in the parent-child session and implemented in the parental
cr
guidance session, serves as a mirror or documentation of the parent-child interaction. Examining this product helps the parents see the change
us
processes that are taking place over the course of therapy. Malchiodi
an
(2007) claimed that art, as a language composed of colors, shapes, lines and images, serves as a tool of expression in a place where words end.
M
Implementing art based interventions in parent-child art psychotherapy uses the non-verbal language of art for growth, insights, and personal
d
transformation, as well as a means for communicating thoughts, feelings,
te
and perceptions of external realities and life experiences. In parent-child psychotherapy, as in group therapy (Yalom, 1995), the pattern of
Ac ce p
relationship formed between the parent and child may be observed in the room in a way that facilitates a relatively quick connection between insights and learning in therapy and their implementation in real life, outside the therapy room.
All the art therapists noted the importance of working on parents'
internalized representations to acquire a better understanding of their child and their relationship with him/her. This is largely supported in work by object relations and relational theoreticians (Fraiberg, Adelson & Shapiro, 1975; Lieberman, Padro, Van Horn & Harris, 2005; Manzano, PalacioEspesa & Ailka, 2005). However, most of the therapists also used some
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degree of practical parental guidance such as providing information on child development. The therapists differed with respect to several issues that might be approached during parental guidance (such as working on
ip t
the parents' jealousy towards the therapist, couples issues, etc.). These issues appear important to therapy, but some of the therapists chose not to
cr
elaborate on them in order to remain focused on the relationship between
us
the parents and the child.
Fourth, most therapists mentioned a variety of ways they encouraged
an
the parents to work with the art supplies during parental guidance (when the therapist meets the parents alone). Art is used in parental guidance
M
according to the same basic concepts of using art in therapy; i.e., as a nonverbal tool for expressing and treating internal content (Betensky, 1995).
d
According to Gavron (2010), the act of creating and observing artwork
te
created drives and processes of "metaphorical insight" (Wix, 1997), which make the art meaningful, not only as describing and representing but also
Ac ce p
as enabling the acquisition of significant internal insights by the participants in this process. The therapists stated that introducing art-based interventions can be helpful in parental guidance but is not always appropriate for specific therapists or parents. The fifth and last idea deals with the parenthood of the parent-child
art therapist which can influence therapeutic work in complex ways. The debate concerning parenting and the ability of a non-parent therapist to provide therapy is not new. Emilia Perroni (2009) discussed the difference between the concepts of motherhood and motherliness, a distinction first made by psychoanalyst Helene Deutsch in 1964. Motherhood describes the
Page 26 of 36
fact that a woman is a mother whereas motherliness is an attribute that expresses an emotional attitude of a woman towards others and towards herself, and is not necessarily related to biological motherhood. Thus art
ip t
therapists who are not parents can possess traits of motherliness, which are essential to expressing appropriate emotional attitudes towards others and
cr
towards oneself. Despite the many advantages of the therapist being a parent, there are also challenges that mainly involve countertransference
us
that the therapist may feel towards the parents. The findings emphasize
an
how important it is for therapists to be aware of issues such as coping with jealousy, possible criticism and influences on the parental functioning of
M
the therapist himself.
This study has several limitations. This study was conducted in
d
Israel, and it is reasonable to assume that studies of the work of parent-
te
child art therapists in other cultural contexts would be beneficial as well. Second, although it is evident that the therapists interviewed here came
Ac ce p
from various theoretical perspectives, the model developed by Ben-Aaron and her colleagues influences the work of most parent-child art therapists in Israel. There are other parent-child models whose exploration could lead to further conceptualizations of parent-child art psychotherapy models. The present research addressed art therapists' own, self-reported perceptions regarding parent-child art psychotherapy. As authors, we did not enter the therapy rooms with the therapists. Hence there may have been differences between these accounts and the actual, objective reality. Follow-up research will continue consolidating and conceptualizing working with parents in the parent-child art psychotherapy work model
Page 27 of 36
(according to additional approaches and models as well). The effectiveness of working with parents in parent-child art psychotherapy will also be further investigated using more research-oriented means, on a broader and
cr
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more heterogeneous sample.
References
us
Ben-Aaron, M., Harel, J., Kaplan, H., & Patt, R. (2001). Mother-child and
disturbances
in
childhood.
an
father-child psychotherapy: A manual for the treatment of relational Whurr
London
and
M
Philadelphia.
Publishers:
Betensky, M. G. (1995). What Do You See? - Phenomenology of Therapeutic Expression. London: Jessica Kingsley Publishers.
d
Art
te
Bion, W. (1967). Notes on memory and desire. In: E. Bott-Spillius (Ed.),
Ac ce p
Melanie Klein today (Vol. 2, pp. 17-21). London: Routledge. Bowlby, J. (1979). The making and breaking of affectional bonds. London: Tavistock.
Charmaz, K. (2006). Constructing grounded theory. London: Sage. Cohen, A. (2007). The Parenthood experience- Coping and Development. Kiryat Bialik: Ach Publisher (in Hebrew).
Daly, K. D., & Mallinckrodt, B. (2009). Experienced therapists’ approach to psychotherapy for adults with attachment avoidance or attachment anxiety.Journal of Counseling Psychology, 56(4), 549.
Page 28 of 36
Edry, A. (2011). Conjoint art work as non-verbal therapeutic communication between mother and child. Thesis submitted in partial fulfillment of the requirements for Master's degree. University of Haifa (in Hebrew).
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Fonagy, P., Gergely, G. & Target, M.(2007). The parent–infant dyad and the construction of the subjective self. Journal of Child Psychology and
cr
Psychiatry, 48, (3/4), 288–328.
us
Fonagy, P. & Target, M. (1997). Attachment and Reflective function: Their
role in self organization. Development and Psychopathology, 9, 679-
an
900.
Fonagy, P., Steele, H., Moran, G., Steele, M. & Higgit, A. (1991). The
M
capacity of understanding mental states: The reflective self in parent and child and its significance for security of attachment. Infant Mental
d
Health Journal, 13, 200-217.
te
Fraiberg, S., Adelson, E. & Shapiro, V. (1975). Ghost in the nursery: a
Ac ce p
psychoanalytic approach to the problems of impaired infant-mother relationships. Journal of the American Academy of Child Psychiatry,
14, 387-421.
Frank, J. D. & Frank, J. B. (1991). Persuasion and healing. Baltimore: Johns Hopkins University Press.
Gavron, T. (2010). Psychotherapy and assessment of parent-child relationships through joint painting. In: "Parent-child Psychotherapy" (2010) Harel, J.
Pat-Avimeir, R. & Kaplan, H. (Eds). Department of
Psychology, University of
Haifa (in Hebrew).
Page 29 of 36
Harel, J., Kaplan, H., Avimeir-Patt, R. & Ben-Aaron, M. (2006). The child's active
role
in
mother-child,
father-child
psychotherapy:
A
psychodynamic approach to the treatment of relational disturbances.
ip t
Psychology and Psychotherapy: Theory, Research and Practice, 79, 23-36.
cr
Hill, C. E., Thompson, B. J., & Williams, E. N. (1997). A guide to conducting
us
consensual qualitative research. The counseling psychologist, 25(4), 517-572.
Ladany,
N.
(2005).
an
Hill, C. E., Knox, S., Thompson, B. J., Williams, E. N., Hess, S. A., & Consensual
qualitative
research:
An
M
update. Journal of Counseling Psychology, 52(2), 196. Hosea, H. (2006). “The brush’s footmarks”: Parents and infants paint together
te
Therapy, 11(2), 69-78.
d
in a small community art therapy group. International Journal of Art
Ac ce p
Irving, L. M., Snyder, C. R., Cheavens, J., Gravel, L., Hanke, J., Hilberg, P., & Nelson, N. (2004). The relationships between hope and outcomes at the
pretreatment,
beginning,
and
later
phases
of
psychotherapy. Journal of Psychotherapy Integration, 14(4), 419-443. doi:10.1037/1053-0479.14.4.419
Kaplan, H., Harel, Y. & Avimeir-Patt, R. (2010). Dyadic Therapy: An Encounter Between the Therapeutic Act and Theory. Department of Psychology, University of Haifa (in Hebrew).
Klein, M. (1975). Love guilt and reparation & other works, 1921-1945. New York, NY: Delacorte Press.
Page 30 of 36
Lieberman, A. F., Padro, E., Van Horn, P. & Harris, W. W. (2005). Angels in the Nursery: The intergenerational transmission of benevolent parental influences. Infant Mental Health Journal, 26(6), 504–520.
ip t
Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic inquiry. Newbury Park, CA: Sage Publications, Inc.
cr
Mahler, M.S., Pine, F. & Bergman, A. (1975). The Psychological birth of the
us
human infant. New York, NY: Basic Books.
Malchiodi, C. A. (2007). The art therapy sourcebook. New York, NY:
an
McGraw-Hill.
M
Manzano, G., Palacio-Espesa, P. & Zilka N. (2005). Narcissistic scenarios of parenting. The clinic for parenting consultation. Tola’at Sefarim (in
d
Hebrew).
te
McCracken, G. (1988). The long interview. Newbury Park, CA: Sage
Ac ce p
McDonough, S.C. (2000). Interaction guidance: An approach for difficult to engage families. In: C. Zeanah (Ed.), Handbook of Infant Mental
Health. New York: Guildford Press. pp. 485-493.
Menninger, K. (1959). The academic lecture on hope. American Journal of Psychiatry, 109, 481–491.
Muir, E. (1992). Watching, Waiting and Wondering: Applying psychoanalytic principles to mother-infant intervention. Infant Mental Health Journal, 13(4), 319-328.Proulx, L. (2005). Strengthening emotional ties through parent-child-dyad art therapy. Jessica Kingsley Publishers.
Page 31 of 36
Perroni, E. (2009). Motherhood: Psychoanalysis and other disciplines. Jerusalem: The Van Leer institute. Ponteri, A. K. (2001). The effect of group art therapy on depressed mothers
ip t
and their children. Art Therapy: Journal of the American Art Therapy Association, 18(3), 148-157.
cr
Proulx, L. (2003). Strengthening emotional ties through parent-child-dyad art
us
therapy. London and Philadelphia: Jessica Kingsley Publishers Ltd.
Regev. D., Kedem, D. & Guttmann, J. (2012). The effects of mothers’
an
participation in movement therapy on the emotional functioning of their school-age children in Israel. The Arts in Psychotherapy, 39, 479-
M
488.
d
Segal, H. (1979) Klein. Fontana Modern Masters.
te
Stern, D. N. (1995). The Motherhood Constellation. New-York: Basic Books.
Ac ce p
Stern, E. (2005). Post-therapy outcome check between Ben-Aaron's dyadic therapy and individual therapy patients. Thesis submitted in partial fulfillment of the requirements for Master's degree. University of Haifa (in Hebrew).
Winnicott, D.W. (1971). Playing and Reality. London, England: Tavistic Publications.
Wix, L. (1997). Picturing the relationship: An image-focused case study of a daughter and her mother. American Journal of art therapy, 35 (3), pp 74-82. Yalom, I. D. (1995). The theory and practice of group psychotherapy. Basic Books.
Page 32 of 36
Yishay, R. & Oren, D. (2006). Blocked parenthood and actualized parenthood - Parenthood as an act of creation and the contribution of dynamic parent
guidance
with
a
psychoanalytic
orientation.
Sichot
Ac ce p
te
d
M
an
us
cr
ip t
(Conversations), 20(3), 251-263 (in Hebrew).
Page 33 of 36
Research Highlights Investigates parent-child art therapists' perceptions about parental
Suggests the importance of parental involvement in therapy.
Ac ce p
te
d
M
an
us
cr
Emphasizes the role of art intervention in parental guidance.
ip t
guidance
Page 34 of 36
Table
Table 1 – Therapist Demographic Information No.
Age
Gender
Setting
Theoretical
Supervisor
Seniority
orientation
Seniority in Parent-
1
42
Female
Private
Psychodynamic,
&
Phenomenologic,
Public
Narativ
Yes
15
5
2
59
Female
Public
Eclectic
Yes
14
6
3
48
Female
Private
Object relations,
Yes
14
5
&
Attachment
Yes
27
Yes
11
4
53
Female
Private
Psychodynamic,
5
39
Female
Private
Psychodynamic,
&
Object relations
Public
26
5
us
Phenomenologic
cr
Public
43
Female
Private
Eclectic
Yes
14
12
7
41
Female
Private
Psychodynamic,
Yes
10
4
&
Object relations,
Public
Family therapy
Private
Psychoanalytic,
Yes
24
17
Yes
12
10
Yes
15
10
No
5
1
Female
Relational 40
Female
Private & Public
10
40
Female
Private
Psychodynamic
ed
9
M
50
an
6
8
Psychodynamic,
ip t
child
11
36
ce pt
Object relations
Female
Public
Eclectic,
Psychoanalytic
51
Female
Public
Psychoanalytic
Yes
13
6
13
56
Female
Private
Adlerian theory,
No
9
5
&
Cognitive-
Yes
30
18
Yes
30
12
Yes
18
15
No
8
4
14
15
Ac
12
61
55
Female
Female
Public
Behavioral
Private
Developmental, Object relations, Relational
Private
Psychodynamic,
&
Phenomenologic
Public 16
55
Female
Private
Psychodynamic, Phenomenologic
17
54
Male
Private
Eclectic - Object
&
relations and self
Public
psychology.
Page 35 of 36
18
55
Female
Private
Psychodynamic,
&
Object relations
Yes
20
15
Yes
20
8
No
8
5
Public 19
50
Female
Private
Eclectic,
&
Psychoanalytic
Public Female
Public
Object relations
ce pt
ed
M
an
us
cr
ip t
42
Ac
20
Page 36 of 36