Journalof SubstanceAbuse Treatment, Vol. 2, pp. lS3-158,198S Printed in the USA. Au rights reserved.

a740-5472/M $3.00 + .oo Copyright o 1986 Pergamon Press Ltd

ORIGINAL CONTRIBUTION

Group Art Therapy in a Methadone Clinic Lobby

EVELYN VIRSHUP, POD, ATR

Institute for Studies of Destructive Behaviors, Los Angeles, CA

Abstract-A weekly group art therapy workshop, held in the waiting room of the Venice (Cali- fornia) Methadone Clinic of the Los Angeles Institute for Studies of Destructive Behavior, is de- scribed. In this workshop, the clients project their imagination onto random lines and shapes made by string and ink on paper drawing out the images they see and writing titles and sometimes stories about them. The artwork b shared, discussed, and displayed in the lobby.

Through this art-centered process, the clients learn to communicate feelings and conflicts with each other. They also develop social skills, gain insight, and improve their self--esteem. Group art therapy, when combined with counseling, b an effective therapeutic modality when working with a nonverbal and resistant population such as drug abusers.

Keywords-Art therapy, substance abuse, methadone clinic, group therapy

INTRODUCTION

DRUG ABUSERS PRESENT a difficult psychotherapeutic problem. They form a complex heterogenous group with early narcissistic conflicts which, in the author’s experience are resistant to verbal treatment modali- ties. From an analytic viewpoint, drug addiction is an attempt on the part of the addict to compensate for developmental and structural defects originating in the non-verbal oral stage Krystal & Raskin (1970).

Drug abuser traits include nonlinear, nonlogical appositional thinking and impulsivity (which makes it difficult for them to pursue a topic or sustain a constructive and maturational line of thought in both individuals and group processes) Virshup (1978). However, these same traits seem to be responsible for the positive response to the process of art therapy in

Dr. Virshup is the director of the Frieda Chaikin Art Therapy Pro- gram of the Suicide Prevention Center, Institute for Studies of Destructive Behaviors, in Los Angeles.

Request for reprints should he sent to Evelyn Virshup, PhD, ATR, Suicide Prevention Center, 1041 S. Menlo Avenue, Los Angeles, CA !NOO6.

group settings. Spontaneous drawings produce ma- terial comparable to a dream. In the somewhat altered state of consciousness typical of creative endeavor, the critical (super ego) faculty of the individual is blocked, thereby allowing access to the previously non verbal, non communicated part of the individ- ual. Art, like dreams, is a “royal road to the uncon- scious.” Moreover, the art product has the advantage that it exists, and can be reviewed as often as desired.

LITERATURE REVIEW

Kaufman (1978) estimated that 5% to 10% of ghetto addicts demonstrate serious psychopathology and that only self-motivated addicts were good candidates for “higher” intervention (i.e., psychoanalytically- oriented) psychotherapies. In his review of the “full range of therapeutic services” for the drug abuser, art therapy was not mentioned.

However, art therapy literature began when Naum- berg first published INTRODUCTION TO ART THERAPY in 1950 (Naumberg, 1973).

Art therapy and substance abuse literature dates back to 1953 when Ulman did art therapy with an outpatient alcoholic group which she structured as a

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154 E. Virshup

“class” with technical criticism, aesthetic suggestions and exercises (Uhnan, 1953).

In a pilot study working with 55 male alcoholic in- patients, Devine (1970) found their artwork conven- tional, rigid and “emotionally empty.”

Harms (1973) recommended one-to-one art therapy based on his experiences at a residential methadone treatment center.

Wittenberg (1974), working with adolescents in a therapeutic community, found “verbal interpreta- tions contra-indicated for young people already sat- urated with verbalization.”

Working with short term groups in a day clinic in Canada, Head (1975) conducted verbal group ther- apy, but also discussed art therapy as an avenue of expression for those who either find it difficult to verbalize or who do not wish to do so.

Working with six to eight residents at a time in a rehabilitation center, Foulke and Keller (1976) without interpretation, encouraged the addicts to express emo- tions verbally which they had first drawn, in a sup- portive environment.

Albert-Puleo and Osha (1977) held twice-a-week 2 hour sessions in a 30 day residential program with groups of six alcoholics, where they gave specific as- signments and interpreted the drawings to the patients.

Donnenberg (1978) described a directive art ther- apy experience with six men in a residential drug-free therapeutic community, using group murals.

Treating a group of 26 acutely depressed men and women drug abusers, Naitove (1978) found their art- work similar in content, with repeated swirling pat- terns, blood, eyes, pills, the cross, and monsters.

Creating a safe, nonjudgmental and permissive en- vironment, Kaplan (1978) described face painting with 10 to 20 adolescent drug abusers in a therapeutic community. After the painting experience, the group was able to discuss topics of trust and non-sexual touching.

Working with 25 addicts at a time in a residential treatment center, Virshup (1978) used the projective technique of string and ink to enable the inarticulate, resistant patients to allow themselves a form of self expression.

Gantt and Howie (1979) described characteristic form and content of art therapy productions from different diagnostic categories, including alcohol and hallucinogen users.

In a review of 20 articles on art therapy with sub- stance abusers, Moore (1983) found a wide range of treatment styles, settings, and psychological orienta- tions.

Describing the concepts determining the field of art therapy in the Journal of Psychoactive Drugs, Kaufman (1981) showed illustrated case studies.

In describing the “modern” art therapy approach

to the narcissistic drug abuser, Albert-Puleo (1980) adapted art therapy techniques to the psychoanalytic viewpoint of Spotnitz. She said, “An easel and com- fortable chair can be used much like the traditional couch.”

Virshup and Virshup (1981) reviewed some of the ways in which group art therapy with drug abusers incorporates principles of group therapy, both ana- lytic and behavioral, as well as adding its own unique value.

THE VENICE (CALIFORNIA) METHADONE CLINIC

Since February, 1982, an everchanging group of methadone users has been participating in a weekly 2 hour group art therapy workshop held in the waiting room of the Venice (California) Methadone Clinic of the Los Angeles Institute for Studies of Destructive Behavior. The program was initiated on a pilot basis to provide an additional therapeutic modality for those persons who found it difficult to express their feelings and conflicts verbally. Initial therapeutic goals for the clients included exploration of their need for drugs, improved interpersonal communica- tion, enhanced self esteem and understanding de- pendency needs.

There are two groups of clients at the Methadone clinic. The first group, entering the outpatient detoxi- fication program may be viewed as generally being in crisis, with specific needs for jobs, food and housing. Understandably, individuals in this group find it dif- ficult to immediately focus on their problems, and are not as yet emotionally prepared to utilize any kind of therapy. The second group of clients, those who join the Methadone maintenance program, value the clinic counselors as well as their daily dose of Methadone. Many of them have been on the pro- gram for several years and are more responsive to the process of art therapy. As a registered art therapist, the author has been leading a mostly nonverbal group of Methadone maintenance clients, using art as the medium of expression.

The lobby is usually occupied by at least a dozen clients waiting for either medication or interviews with their counselors. In the weekly workshops, an average of six clients produce drawings, although clients are not required to participate. In the lobby is a large newspaper covered table, 4 feet by 9 feet, in the center of which are boxes containing soft pastels and two bottles of black poster paint. In addition, there are half dozen “chop sticks” with 12 inch pieces of kite string tied like a fishing line to each, plus 11 inches by 17 inches paper. On the wall behind the table is a large (5 feet by 6 feet) cork bulletin board

Art Therapy in a Methadone Clinic Lobby 155

where everyone’s art (staff included) is hung each week.

Clients begin the process by dipping the string in black ink. The ink-soaked string is then dragged across the paper, making random marks. This creates a sur- face on which there is a wide variety of lines, dots and blots. The clients look for images among the marks and add colors as they choose from the boxes of pas- tels. As each picture is finished, the client is asked to title the work and write an accompanying explanatory story. Titles are easy to come by; stories are not.

At least 150 clients have participated in this project during the past 2% years. Many have continued with the art group for several months and have involved their children as well. To illustrate the process, the productions of one of the clients is discussed in detail.

CASE PRESENTATION

Donna, a married 35 year old Caucasian woman, was a drug abuser since high school. Both she and her husband Robert had used heroin for 20 years and were both subsequently enrolled in the Methadone detoxification program.

Their developmental history revealed both families of origin to be deeply involved in substance abuse and violence. Donna was married at age 19 but had been abandoned by her first husband, leaving her with two baby boys, now 12 and 15. Robert’s first wife died of an overdose, leaving him with two babies, a girl now 16 and a boy 18. They were raised by his Mexican-born mother. Donna and Robert met, mar- ried and proceeded to have two girls of their own, now 3 and 4. They have lived at poverty level since their marriage. Robert, with no job skills, found oc- casional odd jobs, while Donna was unemployed.

Donna was emotionally immature, and had formed a nonfunctioning symbiotic relationship with Robert. She demonstrated severe feelings of inadequacy, poor parenting skills, and even fewer skills in dealing with the world. She did not communicate well and was rel- atively inarticulate in discussing her many problems.

Initially, she had tremendous feelings of inade- quacy while drawing. The blank paper aroused great anxiety, reminding her of a lifetime of failure. Her only exposure to art heretofore was some tracing paper projects in elementary school. She was not “talented”. However, as she continued working with the string and ink, she gained considerable confidence and even took art materials home. She and her hus- band did many drawings at home, some of them fairly accurate renderings of flowers and birds. Donna’s drawings were quite representative of the moderate quality of art being produced by the group: however the only art critique ever used was “Wonderful! Mar- velous! I like it! ” Donna was often heard to repeat

the self-deprecating comment “Oh, Evelyn likes every- thing!” Nevertheless, because of her “successes,” Donna became highly motivated.

In addition to an evident increase in her self-moti- vation, the titles she gave her pictures often stimu- lated her to discuss their symbolism and significance to her personally. Although she resisted verbal ther- apy, the art process did not seem to threaten her and frequently led to issues that were important to her and to the group.

A description of some of her drawings and a dis- cussion of some of their effect on the group process follows:

1. In her first drawings, there was confusion. She was unable to pull any order out of the random marks on paper. She entitled it Managerie (sic), and said that was how she felt about her family.

Newcomers to the process of art therapy often re- spond this way. They see the mass of lines as a mirror for their own confusion. The thought of drawing may strike them as funny, or as frightening. Initially they find it hard to believe that they are actually being asked to draw. Some of them are suspicious, having experienced the Rorschach test in prison. However, Donna, like many others, understood the process within minutes, and participated willingly.

2. In one of her first ordered drawings, she found a woman’s face, and called it Housewife Blues. Using this as a springboard, we were able to deal with her feelings of being trapped in her role of housewife, and her conflicts with Robert about returning to school. He didn’t want her to be more educated than himself.

Many of the women in the group were reluctant to complain about their own roles, but they became em- pathic and supportive of Donna’s feelings of frustra- tion. The men argued with her point of view. The women gave her suggestions for nursery school for her two clinging girls and encouraged Donna in her desire for a high school diploma.

156 E. Virshup

3. After showing the drawing she called Father Time, she told the group about her fear of aging, how empty and wasted her first 35 years seemed to her, and how futile she felt about what lay ahead of her.

The group identified strongly with these.issues and although many didn’t talk, they listened. She reported that her progress troubled Robert, not only in her edu- cational and emotional development but in her ability to detox faster. We explored options and her earlier interests, going back to before she dropped out of high school. One of the options discussed was family therapy.

4. After drawing a huge redface called Angry Husband, she decided that she was angry also. She wrote a long story about her fear of expressing anger and the group talked about productive ways for her to release her stored-up rage. The problem was “not theirs,” of course, but still it seemed to have a lot of meaning for them.

5. In a drawing of a Sad Clown, she was able to talk about her sense of not valuing herself and being seen as helpless and foolish. She talked about feelings of shame and inadequacy. Having finally expressed these hidden secrets, we went on to find things she could feel good about, like her interest in nutrition and body building, her aesthetic side and her fastidi- ous appearance even through her years of heavy drug use. The group tentatively acknowledged their own “clowns,” and their feelings of inadequacy.

Art Therapy in a Methadone Clinic Lobby

6. Her most recent drawing of a huge mustached face, which she called Strength Inside Me, referred to how good she was beginning to feel about withstand- ing pressures in her family and asserting herself. We were able to talk about ways of becoming more asser- tive, a quality sorely missing among the clients at the clinic.

Donna’s dose went down to 10 milligrams of Meth- adone, allowing her and the art therapy process to reach many conflicts which were previously immo- bilizing. However, my prognosis remains guarded due to the length of her involvement in heroin, her fusion with her husband, and her generally low ego strength.

DISCUSSION

The Methadone users’ art therapy group functions on a walk-in basis. Some of the clients are on the 21-day detoxification program, others are on the maintenance program, and the composition of the group changes constantly. Therefore intimacy is not easily estab- lished and open verbal communication is difficult to elicit.

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Observations

The Focus is on The Artwork. Despite situational dif- ficulties, the clients become absorbed in their produc- tions, the novelty of using colors, and finding images. Focusing on the artwork rather than verbal communi- cation takes pressure off what they had always felt as a real problem, their lack of verbal ability. Absorbed in fantasy-making, in a relatively new environment, without the focus of art as product, they are able to express many thoughts and feelings in images which they otherwise would never have discovered or re- vealed. The power of art as a language brings forth many denied images. Their defenses are lowered be- cause the problem is once removed to paper.

The Artwork is Shared Publicly, Creating Effective Group Process. Because of the public nature of the workshop, focus is not on individual psychodynamic processes. Like parallel play of young children, the process of the art workshop permits all the group members to express their feelings simultaneously, without interrupting each other.

The others’ artwork become mirrors of their own, and they can see how similar their symbols and prob- lems are, giving them the choice of confronting them- selves nonverbally or verbally. They receive feedback from the group about the various issues which arise, which they are free to discuss, or they may lapse into silence, if they choose. The play quality about the art process allays anxiety to the point where they focus on their problems with relatively little denial. Thus it allows the participants another way to express their feelings in a safe environment, to lower their anxiety levels and perhaps permit their creative problem- solving juices to flow again.

The Artwork Represents a Graphic Projection of Their Inner Conflicts. The art therapy technique combines the characteristics of common projective techniques. It is similar to the image-evoking inkblots of the RORSCHACH TEST, bringing forth uncon- scious material, and combines this with the revealing story-telling techniques of the THEMATIC APPER- CEPTION TEST. In addition, it is visible and semi- permanent.

The Clients Have Gained in Self-Esteem. All draw- ings are pinned on the wall, and many of the clients are amazed that they are capable of producing some- thing everyone considers of value. They immediately recognize that their artwork has personal significance to them. They are proud of their efforts and show off their drawings to their friends.

158 E. Virshup

The Stereotypical Picture of The Drug Abuser Has Been Altered. Visitors to the clinic, social workers and other agency people not involved in the drug cul- ture come through the lobby and express admiration for the artwork and the artists. More importantly, it is the author’s conviction that they gain understand- ing of the individuality and personal meaning the drawings have for each person.

The ambience of the waiting room has been trans- formed. Previously, people have sat in silence, wait- ing for their dose or a visit with the doctor. Now, throughout the week, the artists as well as other cli- ents discuss the drawings on display, relating the sig- nificance of the titles to themselves and establishing relationships.

The Counseling Staff Also Has Found Value in The Process of Art Therapy. They view the drawings weekly and discuss them with the clients in their pri- vate counseling sessions, focusing on problems which have been highlighted in the pictures. Indeed, they have frequently joined in and learned to use the pro- cedure as a new communication tool for themselves. Some of the counselors have reported their own in- terest in the arts enhanced by understanding the “lan- guage” of art therapy.

CONCLUSION

The Lobby Art Therapy Program is a successful mode of therapy for the drug-abusing population. It has been effective in helping clients become more open and expressive about their basic problems and their own dynamics in a non-threatening therapeutic milieu. Art therapy done in this communal manner influences many resistant people who have not yet allowed them- selves to be touched by the more traditional therapies. Group art therapy, when combined with counseling and therapy, is an effective therapeutic modality for working with a very difficult, often non-verbal and highly resistant population.

At the present time, this conclusion is based on the clinical impressions of workers in this field. A critical study to validate these impressions was solicited and approved by NIDA to the author in 1980, but the funding has not so far been forthcoming. It is likely that funding is difficult to obtain because no empiri- cal studies demonstrating its worth have yet been funded. The clinical evidence suggests that such a study is needed.

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