Using Person Centered Therapy with Forensic Population

Recently, I asked on of the art therapists to talk about his experiences using person-centered therapy with forensic patients. He had used this kind of therapy in his past work, and was able to see progress with a forensic patient he worked with. He talked about the three principles of unconditional positive regard, empathetic understanding, and congruence. This led to a good discussion including the use of asking questions of patients, and using a variety of therapies when treating patients. We all did a piece of art work about a time we used person-centered therapy with a patient, and then talked about the experience. 

Gratitude Tree

For one art therapy supervision, we created a Gratitude Tree. Each person cut out several paper leaves. Then we wrote down things we were grateful for, skipping the obvious "friends and family" ones. One art therapist was thankful for small health advances made after major surgery. Others wrote their favorite foods and drinks. Spa days, TV shows, and travel experiences were other items written. Then everyone helped make the tree trunk and branches, and we taped it to the wall and added our leaves. The tree looks cool, and we made an envelope with blank leaves, so more could be added. It was a nice self care activity to remind ourselves of thing we enjoy and appreciate. It also served to help the group get to know each other better. 

Zentangle drawing

In April, a colleague and I attended a Certified Zentangle Teacher training Seminar in Providence, RI. Creating Zentangle tiles is a meditative drawing method that can help increase focus and decrease stress. It is easy to learn and has many applications. For example, you can create Zentangle-inspired art like greeting cards, decorative boxes, picture frames, or bags. Now, we are facilitating a group for the patients at the hospital as a way for them to enhance their leisure skills, be creative, and do something relaxing. We have also taught staff the drawing method for self care purposes or just to enjoy something artistic. For more information, visit www.zentangle.com. 

Power Thought Cards

For supervision last week, I asked everyone to fold their paper in half. I asked everyone to create an image on one side of a problem, difficult patient, or challenging situation. After they did that, I passed around some Power Thought Cards (box of 64 by Louise Hay) with various sayings on the front and back. I asked everyone to choose one that resonated with them or related to the image they drew, and then create another image on the other half of the paper related to the card they chose. Some therapists drew about a challenging patient, other's drew about difficulties with other staff. The Power Thought Cards served as an inspirational idea or a positive affirmation. The cards are useful in groups with patients as well. I used them in my poetry group as inspirations for poems, and in my Visual Journaling group as inspiration for stress management and coping skills. 

Snowflake Directive

For supervision last week, I had everyone cut out a snowflake. I provided instructions on how to fold a six pointed snowflake, and to cut small shapes out of it so it stays intact. After everyone cut out their snowflake, I asked them to write things on it that made them unique, reminding them that it was a combination of all their qualities, characteristics, and experiences that made them unique. This directive could also be used with patients as a self esteem directive or the snowflake making process as a problem solving directive. It was nice to hear what people thought of themselves and how they felt they were special.

Mask Directive

For Halloween, we decorated masks during supervision. The directive was to represent your scariest self. This exercise served to help the therapists be more aware of all aspects of themselves. When working in forensics with patients with very dark sides, it's important to be in touch with one's own darker places. This can offer some insight into ourselves as well as our patients, and may help us deal with them more effectively. Exploring what drives us, triggers us, or angers us can help us understand ourselves better, feel empathy for our patients, and formulate ways to interact with them. 

Group Scribble Drawing

During a recent supervision, we made a group scribble on a long piece of butcher paper. Each person chose a different color marker and we took turns making a scribble to fill up the page. Then everyone was invited to walk around the paper to see what images they could find in the scribble. Then, everyone could use whatever media they wanted to bring out that image. It took a few minutes to get going, but soon images were being pulled out all over. This is a good exercise to get people to loosen up and use their imagination. It can also be good for clients to address problem solving or boundaries. 

Setting professional goals

In a recent art therapy supervision, I asked everyone to think about their professional goals as an art therapist, either short or long term. Sometimes setting specific goals and/or talking about them can help us motivate ourselves and enable us to help and support each other in our endeavors. One therapist talked about working on some personal issues that would help her interactions with others. Other therapists talked about working toward their ATR or other licensure. One shared about an interest in play therapy while another said he would like to become a psychoanalyst. Attending trainings, presenting at conferences, and doing research were also discussed. It was a good way to learn about each other, and I talked about the importance of helping our patients set and meet their goals as well. 

Boundaries workshop

At a recent conference in a forensic setting, another art therapist and I had the opportunity to offer an art therapy experiential on boundaries. We asked participants to think of a time that a patient crossed their boundaries and to create an image about that. Participants were invited to show their art work and talk about their experience. One person talked about a patient who grabbed her, another shared about a patient who was being manipulative with him, and another new staff told of a patient trying to intimidate her. Discussion included ways to develop rapport with patients without physical touching and setting clear verbal limits as well as other ways to deal with patients with poor boundaries. Participants were able to offer each other feedback and tips. The group discussion illustrated that we were not alone in our challenges in dealing with boundary issues with a difficult population, and were indeed able to support one another. 

Remembering your strengths

In a recent art therapy supervision, I asked the group to think of a time when they felt physically and/or mentally strong and create an image about that. People shared various experiences from being forced to do sports to learning how to ride and train horses to coping with a child's illness. Then I asked them to think about a time they had to be strong since they started working at the hospital, and how they have used their strength to manage in their jobs here. Some of the situations we face with the patients, and even other staff, require us to use mental strength, and it is important to remember that we all have strengths to call upon when needed. 

Termination issues

We have an art therapist who is retiring soon, and he is concerned with how to terminate with patients at the hospital--on his unit, and in his groups. I asked everyone in the supervision group to create an image about a time they had to say goodbye to someone, and then asked them to think about the feelings they had at the time. These feelings are comparable to what the patients feel when they have to say bye to therapists who leave the facility, but because they are patients with various issues, their feelings may be amplified, difficult to identify, and harder to express. We discussed how it is the therapist's responsibility to give the patient enough time to process his feelings and still have the opportunity to talk to the therapist about those feelings. 

Self-disclosure directive

One of the art therapists suggested this topic, so in supervision, I had everyone make a collage of info or topics they felt comfortable sharing or talking about with patients, and those they were not comfortable with. One therapist said she talked about her dogs in the pet therapy group while another therapist said she never talks about her pets with the patients. We discussed times we revealed too much, we overheard other staff disclosing too much, and what to do if you felt your co-facilitator was sharing personal information during a group. We also talked about how to deal with patients who ask personal questions, as sex offenders commonly do. Everyone has his or her personal boundaries, and the therapists were asked to think about theirs, and when sharing personal information to think how or if it is therapeutic and beneficial for the patients to know. 

Bob Ross and mural making with patients

When I first started working at the hospital, I ran a mural group to help the patients with their interpersonal skills as well as make a group mural that could be displayed in the hospital. Each group that I ran had difficulty making decisions in order to actually complete a group mural. Recently, a patient became interested in learning to paint via Bob Ross DVDs. He became proficient in the techniques and got peers interested in painting. A small group of patients decided to paint a mural using a Bob Ross instructional DVD. They were able to work together and complete a 4'x6' mural in about 10 hours. They got a couple of other patients interested in mural painting, and they recently completed their 3rd mural. The first one is hanging in the Visiting Room as a backdrop for photos. The use of the DVDs ensured success and prevented the need for a group leader to make compositional or technical decisions. The patients worked companionably, helping and supporting each other. This was a helpful tool to use with populations that are narcissistic or otherwise have difficulty working with others. 

Touchstone craft project

For Art Therapy supervision today, we all made touchstones using clear acrylic stones. We cut images or sayings from magazines that were meaningful or inspirational to us. Then, we used mod podge to adhere the images to the stones. A couple of the Art Therapists weren't that into it in the beginning, but at the end had made several unique touchstones.  One Art Therapist said it was a nice way to relive memories. Some made stones for themselves as well as gifts for others. They could be made into magnets as well. It was a fun activity to do before the holidays. 

Expressive Therapies Summit in NYC

Earlier this month, a colleague and I presented at the Expressive Therapies Summit in NYC. Our presentation was on the use of art therapy to address dynamic risk factors in sex sex offenders. It was a great experience and we were also able to attend some other interesting presentations. I attended a workshop about the Lahad six part story which I shared with my fellow art therapists when I returned from the conference. I also attended a workshop on visual reflection and narrative therapy. My colleague attended a felting workshop and made some very cool projects. It was great to learn about new methods and techniques, and meet other expressive therapists. It was a very refreshing and inspiring experience. 

Experiencing countertransference

Since we have several new art therapists, I wanted them to be more aware of transference and feelings of countertransference that they may experience with the sex offenders at the hospital. So, I asked the group to create an image about a time they felt countertransference with a patient. Countertransference implies there is transference by the patient, but we used a looser definition to encompass any strong reaction to a patient. Many therapists had patients who reminded them of someone they knew, so in those cases, it was important for the therapist to be aware of potential reactions, and to possibly address any personal issues through their own therapy and supervision. Some therapists felt that they were treated as a parental figure, and had to be careful of their care taking feelings. Other therapists felt that they were being flirted with, and had to think about their feelings in response to that. It is important to be aware of countertransference and other strong feelings we have about patients when working in forensics as the patients can be very charming and manipulative as well as angry or self-loathing. Not being mindful can lead to boundary violations and inappropriate or unprofessional behavior. Supervision provides an opportunity for discussion, more self-awareness, and support by peers.

Meditation using art

I was reading about all the benefits of meditation, so I've been trying to practice it more. In a recent Art Therapy supervision, I handed out a bunch of images of art work cut out of a desk calendar that a colleague gave me. I asked everyone to choose an image that appealed to them, and put it in front of them. Then, we closed our eyes and focused on our breathing for a few minutes. Next, we opened our eyes and looked at our image, observing the colors, lines, composition, etc. After that, I asked everyone to to close their eyes again, and imagine stepping into the image, then explore it.  Then, we "exited" the image, and opened our eyes.  I then had everyone create an image about their meditation experience. One person said she had had a headache all day, and that it went away after our short meditation. This can be done as a supervision exercise for self care or as a directive with patients.

Supervision--Feeling frustrated

After a few frustrations with patients during the week, during supervision, I asked everyone to create an image about a recent frustration. I was thinking everyone would have a work related frustration, but most images were about frustrations about life in general, from medical issues to buying a house, to dealing with friends' issues. Then I realized that while everyone probably had experienced frustrations with patients or staff during the week, their other frustrations might be more troublesome or even impact their work, if not dealt with. It was a good opportunity to vent and to also gain support from others, which was the main point of the exercise in the first place.

Yourself represented by the natural environment

During a recent Art Therapy supervision, I asked for a suggestion for a directive. One therapist asked us to draw ourselves/energy as an element in nature. It was very interesting that each of us chose something different, from a volcano to a tornado to lightening to wind to a body of water. Each of us got to say how our drawing represented our personalities, and we were able to hear feedback from peers that offered us a different perspective. A good directive for supervision or an Art Therapy group/session.

Termination with patients

In a recent Art Therapy supervision, we discussed how to terminate with patients.  Since we work in a long term facility, it would be more common that the therapist would leave before the patient, though the termination would be similar if the patient were to be discharged. We've had therapists in the past who have left without telling patients in their groups that they were leaving which is unethical and unprofessional. Saying goodbye can be difficult for anyone, even a trained therapist, but it is the therapist's responsibility to know if this is an issue for her/him and seek supervision or therapy, so the therapist will be able to properly terminate with patients. We talked about the importance of giving patients as much notice as possible, so they can process any feelings that come up about loss, rejection, or abandonment. It is also good for the therapist to be able to say a meaningful goodbye. I had a couple of therapists practice how they might inform a group of patients that they were leaving while the rest of us role played the patients. It is also important with the sex offender population to terminate appropriately because many of them have issues about women, and we wouldn't want to reinforce any of their negative beliefs by terminating improperly. The role playing was a good exercise to help staff think about how they would handle termination.