ACQ_Vol_11_no_3_2009

The drawn “case” then functions as a visual metaphor for the child, making an abstract concept more concrete, and providing the child with a way of both visually and verbally representing him or herself. As the therapeutic engagement develops, the art therapist as case manager invites the child into an ongoing dialogue about the “case” using questions such as “What have you been doing with the case this week?”; “What do you want to get out of (put into) the case this week?”; “How can I help you with the case this week?” The “case” has a transitional role. It is the container of the child’s problems, fears and worries as well as hopes and expectations. However, it is not the whole child. The child achieves a certain distance from the case and can join with the case manager in working out how to deal with problems that are either in the case or associated with the case. The case manager is there to manage the case but not the child. The case manager is usually the primary individual therapist (Kanter, 1989) and draws on the therapeutic framework and repertoire of therapeutic techniques in which she or he has been trained. When the case manager is an art therapist, it follows that much of the individual work with the child will utilise art therapy, as the following case illustration shows. A 10-year-old boy with long history of severe emotional and physical abuse and deprivation with impulse control, attention deficit, and attachment problems was referred to the service following multiple suspensions from primary school. At the time of the referral he was incapable of participating in normal classroom activities and was spending just an hour or two each day in special one-to- one learning activities. Even these sessions often ended in eruptions and physically aggressive outbursts. In the initial interview, he exhibited extreme anxiety, pacing around the room unable to sit down at the table the art therapist, as case manager, had prepared with art materials on it. The case manager asked him “if you had three wishes what would they be?” and suggested he use the big white- board with a photocopying function to draw on – hoping that the use of gross motor skills would dissipate his nervous energy. He produced a car (Figure 2) including himself with Artwork and play in assessment and the therapeutic work of case management

toys (Figure 3). Finally he drew a cannon, which he wanted so he could “shoot everyone away”. In his drawings he revealed his needs both for intimacy (the teddy) and his need for control in the face of fears of obliteration (the car and the cannon). This assessment led to the development of an art and play activity which gave him opportunity both for control and for connection with his therapist. The activity, which extended over much of the term, revolved around a remote-controlled Meccano car. He wanted the car and was prepared to earn the kit by cooking and serving lunch for the staff team (with the assistance of the case manager). The kit consisted of 413 pieces that he and the case manager assembled together over eight weeks. He was more keen on driving than building the car so a compromise was made by which he could drive the partly built car for a while after each session of building. In the building process, he took the role of mechanic, directing the process, while the case manager assisted by sorting the components and assisting with some of the fine motor tasks that were too difficult for him. In addition to building the car, the client and art therapist worked together to make traffic signals (red, amber and green) which were used in driving sessions to establish external controls for the car. The car with wheels and a partially finished body became an external representation of the young person as a work in progress - who was able to stop, start, and move around, subject to a set of non- arbitrary external controls. Discussion The art therapist brings a framework that affirms the value of art making as a means for both expression of complex phenomena such as emotions and communication through metaphor. While art therapy can be an intervention in its own right, it particularly lends itself to application in a multidisciplinary setting. Art making provides another dimension to the verbal, behavioural, and medical interventions that are characteristic of treatment of children and adolescents with severe mental health problems. The first example of the application of art therapy in a specialist CYMHS service shows how art therapy can be successfully integrated with a psychological intervention to provide a rich group experience. Mindfulness is widely used in contemporary evidence based psychological interventions because it promotes self-awareness in a manner that is non- threatening and typically anxiety reducing. The addition of art therapy extends mindfulness into domains of expression and communication. Art therapy promotes enhanced awareness of emotions and providing a medium for communication with peers about these emotions. In the creation of this collaborative group activity, the art therapist and the psychologist enhanced their practice frameworks and created a coherent experience for participants that was both enjoyable and an opportunity for learning and development. The second example shows how the art therapist can bring specific skills and techniques to the work of case management. A core task in case management is the development of a collaborative trusting relationship. This enables the case manager to identify client needs, develop a multidisciplinary treatment plan, and monitor the effectiveness of the plan. Children with complex mental health problems often struggle in purely verbal environments. With such children, art and play provide a medium for

Figure 2. The car

Figure 3. Teddy plus

arms at the steering wheel but with no legs or foot-controls for breaking or acceleration. He said he would like to own a V8 with mag wheels. He then drew his second wish which was a teddy with arms and legs and said he wanted more

138

ACQ Volume 11, Number 3 2009

ACQ uiring knowledge in speech, language and hearing