Visual Art Therapys Unique Contribution in The TR

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Visual Art Therapy's Unique Contribution in the Treatment of Post-Traumatic

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Article in Journal of Trauma & Dissociation · February 2005

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Visual Art Therapy's Unique Contribution in the

Treatment of Post-Traumatic Stress Disorders
Dalia Avrahami MA
To cite this article: Dalia Avrahami MA (2006) Visual Art Therapy's Unique Contribution in the
Treatment of Post-Traumatic Stress Disorders, Journal of Trauma & Dissociation, 6:4, 5-38, DOI:
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Visual Art Therapy’s
Unique Contribution in the Treatment
of Post-Traumatic Stress Disorders
Dalia Avrahami, MA
Downloaded by [92.222.237.34] at 22:17 29 January 2016
ABSTRACT. This paper describes visual art therapy as an integrative

and unique approach, which is most appropriate for the multidimen-
sional treatment of post-traumatic stress disorder (PTSD). The unique
contribution of visual art therapy in the treatment of PTSD is expressed
in three major areas: (1) working on traumatic memories, (2) the process
of symbolization-integration, and (3) containment, transference and
countertransference. Two case descriptions of traumatized patients treated
in visual art therapy are presented. [Article copies available for a fee from
The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address:
<docdelivery@haworthpress.com> Website: <http://www.HaworthPress.com>
 2005 by The Haworth Press, Inc. All rights reserved.]
KEYWORDS. PTSD, dissociation, biographical continuity, integrative

process, visual art therapy, symbolization, combat trauma
Post-traumatic stress disorder (PTSD) is a psychiatric syndrome that

can develop after exposure to a traumatic event–either directly in its
Dalia Avrahami is affiliated with the Kibbutzim College of Education, Beit Berl
College–School of Art, Israel.
Address correspondence to: Dalia Avrahami, MA, 15 Shimoni Street, Ramat Aviv,
Tel Aviv, Israel 69026 (E-mail: avdalia@yahoo.com).
The research and art therapy sessions described in this article took place at the Tel
Hashomer Hospital–Battle Shock PTSD Sufferers’ Workshop.
This article was adapted from Avrahami, D. (2002). Visual art therapy in the treat-
ment of post-traumatic stress disorder. Sihot: Israeli Journal of Psychotherapy, 17(1),
27-36, published in Hebrew.
Journal of Trauma & Dissociation, Vol. 6(4) 2005
Available online at http://www.haworthpress.com/web/JTD
 2005 by The Haworth Press, Inc. All rights reserved.
doi:10.1300/J229v06n04_02 5
6 JOURNAL OF TRAUMA & DISSOCIATION
wake or even long after the original event. Characterized by the recur-
rent re-experiencing of the traumatic event on one hand and amnesia
and psychic numbing on the other, it is accompanied by a variety of
dysphoric, cognitive and autonomic symptoms that may cause long-
term disturbances of emotions, behaviors and personality (American
Psychiatric Association, 1994).
Stress disorder research has demonstrated that persons with PTSD
often have only fragmented, dissociated and nonverbal recall of the
traumatic events (Van der Kolk, 1994; Van der Kolk & Fisler, 1995).
These finding are supported by clinical observations that dissociated
traumatic memories are inaccessible to verbal memory, leaving trauma
victims in a state of “unspeakable terror.”

Visual art therapy offers a unique approach for working with PTSD
patients. The modality allows the trauma to “speak” in its own
language–the visual form. It enables the client to contain the boundless
chaos of the trauma within the borders of a concrete art product, relate
the trauma’s story without verbalizing, and undergo a process of inte-
gration (Greenberg & Van der Kolk, 1987). The art therapy modality
not only enables the exposure and discovery of forgotten memories, it
also facilitates the client’s development of a sense of control over past
and present. (Spaletto, 1992).
THE CONTRIBUTIONS OF VISUAL ART THERAPY

TO PTSD TREATMENT
Visual art therapy is a therapeutic process based on spontaneous or
prompted creative expression using various art materials and art tech-
niques such as painting, drawing, sculpture, modeling (clay or substi-
tutes), collage, etc. It offers a nonverbal language to express emotions
and focuses on the way the client works and creates. The artwork prod-
ucts document the therapeutic process, enable their creators to hold a di-
alogue with themselves, and are lasting objects that can be related to for
a long time. At the heart of art therapy lies the healing power of the cre-
ative process and the special communication that takes place between
the client, the artwork, and the therapist. Although the art expresses the
suffering, it also calls to the creative, healthy part of the client, which
enables an authentic, non-threatening expression, opening new possi-
bilities for change and growth.
Art therapy makes unique contributions in working with victims of
PTSD in three principal areas:
Dalia Avrahami 7
1. Processing of traumatic memories.

2. The process of symbolization-integration.
3. Containment, transference and countertransference.
Processing of Traumatic Memories
Traumatic memories differ from ordinary memories (Brett & Ostroff,
1985, Chu, Frey, Ganzel & Matthews, 1999; Herman, 1997; Johnson,
1987; Scaer, 2001; Shalev, 1994; Van der Kolk, 1994; Van der Kolk &
Fisler, 1995). Unlike normal adult memories, they are not coded in a
verbal and linear framework that can be assimilated in an ongoing life
story. They are by nature frozen and mute. They have neither plot nor
verbal context. They are automatic, triggered and disconnected from or-
dinary life. They are coded in vague emotions and vivid pictures. Thus,
non-integrated memory is considered the basis for behavioral reen-
actment, somatic sensation, or intrusive images as flashbacks that are
disconnected from conscious, verbal memory (Chu et al., 1999).
Concepts such as “imprinting” or “burning” (Shalev, 1994) assume
that memories etched into the fabric of the neural network have a central
function in the formation of PTSD. A number of researchers emphasize
the dissociative character of these memories (Johnson, 1987; Nemiah,
1998; Van der Kolk & Van der Hart, 1989). According to their theory,
portions of the traumatic experience are stored in memory as isolated
fragments of sensory perceptions, emotional states of visual images. In-
tense emotional arousal at the time of the trauma disrupts the normal
storage of information as a narrative memory, leaving traces of the trau-
matic memory in the form of unconscious, rigid, fixed fragments that
are not perceptually integrated with other memories though normal as-
sociative connections. These memory fragments or traces cannot be in-
tegrated until they become more fluid and translatable into a personal
narrative. The dissociative process serves to protect the sufferer from
the intense pain of the experience.
Johnson (1987) suggested that when the sympathetic nervous system
is extremely aroused, as in a traumatic situation, verbal encoding of
memory shuts down and the central nervous system returns to the sen-
sory-iconic memory form reminiscent of early childhood.
Scaer (2001) defines dual memory storage systems:
1. Declarative memory, which is conscious, accurate, verbal and

imaginal recall of the traumatic event.
2. Procedural memory, which is unconscious and relates to acquisi-
tion of motor skill habits, to the development of emotional mem-
ories and associations and to the storage of conditioned sensorimotor

responses.
Scaer assumes that although declarative memory may account for

much of the arousal-based cognitive symptoms of PTSD, procedural
memory provides the seemingly unbreakable conditioning like that per-
petuates the neural cycle of trauma and dissociation.
Bringing traumatic memories to light is accompanied by intense
emotions. Observations during an outburst of traumatic memories sho-
wed decreased activity in Broca’s Area–the region of the brain that is
involved in translating subjective experiences into speech, and signi-
ficantly greater activity in areas of the right hemisphere associated with

emotions and visual images (Van der Kolk, 1994).
Kluft (1992) asserts that clients dealing with traumatic memories
need to learn a new way of nonverbal and non-dissociative coping. Art
therapy has a unique contribution in this situation. Artistic expression
has been widely used for healing purposes in rituals and ceremonies
throughout human history. The artistic activity provides an essentially
nonverbal, therapeutic space, and a tangible, concrete medium within
which a wide range of means and materials can be chosen to arouse the
creative process for healing and change (Greenberg & Van der Kolk,
1987; Jung, 1966; Kramer, 1980; May, 1980; Storr, 1973). Fuhrman
(1992) has noted that artistic expression is naturally found with those
suffering from dissociative disorders, many of whom naturalistically
use art expression as a form of expression, and that their spontaneous art
processes may help their recovery.
Encouraging the pictorial expression of the client’s inner experience,
art therapy communicates with the trauma in its own language–a lan-
guage of shapes, colors and sensations. This process enables dissociated
materials stored as visual memories to reach consciousness and be ex-
pressed. Through art, fragmented traumatic memory can assume a con-
crete form in which the complete experience is visualized (McNiff,
1975).
Using a variety of art materials enables the client to identify and ex-
press emotions, and to create connections between memory and feel-
ings. Art therapy considers the use of art materials as facilitators to
break down defenses and ease the discovery of emotions accompanying
memories (Cohen, Barnes & Rankin, 1995; Kagin & Lusebrink, 1978).
The choice of the materials enables the inner world to be exposed in a
controlled and prudent manner. The transition from working with con-
trollable materials (e.g., pencils, collage, photographs) to less manage-
Dalia Avrahami 9
able, fluid materials (e.g., clay, liquid paint) enables a gradual shedding
of defenses, reflecting an increasing ability to cope with the feelings
that arise.
Art therapy promotes healing among various age groups suffering
from PTSD resulting from many causes and events such as war, vio-
lence, sexual abuse, natural disasters, etc. Roje (1995) reports that art
therapy was used in therapeutic intervention with elementary school
aged children who were victims of the 1994 Los Angeles earthquake.
Roje maintains that art therapy intervention with these children was not
only influential, but also had a long lasting effect. Morgan and Johnson
(1995) compared work on traumatic memories of combat trauma vic-
tims using verbal versus artistic modalities. They observed that artistic
tasks proved to be more effective and had greater, long-term influence
on the client’s life, fostering significant emotional changes and the
integration of traumatic materials.
The use of art therapy for treatment of children, victims of sexual
abuse, is widely mentioned in the literature (Allan, 1998; Brooke, 1997;
Malchiodi, 1991, 1997, 2001; Miller, 1991; Rubin, 1984; Spring, 1993;
Zommer & Zommer, 1997). Malchiodi (1991, 1997, 2001) created an
art therapy program for children exposed to domestic violence, physical
and/or sexual abuse, and neglect. In her opinion, art therapy contributes
both to the diagnostic assessment as well as to the ongoing therapeutic
process. Zommer and Zommer (1997) describe the therapeutic process
of a young girl suffering from a dissociated identity problem, part of a
post-trauma response to four years of sexual abuse by her father. The
authors report that her artworks towards the end of the treatment period
revealed the integration of the fragments of the self that broke down un-
der the weight of the trauma, identifying a new self free of the former
self’s victimized identity.
The Process of Symbolization-Integration
Investigators of post-traumatic phenomena (Spaletto, 1992; Stronach-

Buschel, 1990; Van der Kolk & Fisler, 1995) note that PTSD sufferers
lose the ability to use symbolization–the translation of visual and sensor-
imotor representations into significant, representative and relevant sym-
bols. Consequently, they have a diminished capacity to cope with
everyday injuries and conflicts, and lack the emotional flexibility to ac-
crue positive, healing experiences. Art is part of the symbolic space that
mediates between internal and external worlds (Heidegger, 1992;
Kreitler & Kreitler, 1979). Visual arts use the visible language of line,
shape, composition and color to create symbolic images that appear

spontaneously and contain ideas, emotions, memories, and experiences.
By working and being in a symbolic artistic arena, the client enables the
rehabilitation and growth of this diminished capacity.
The symbolic image is the core of the healing process. The word
“symbol” comes from the Greek concept meaning “to throw together”
or to unify (Lavie-Or, 1993). Thus, the process of symbolization is one
that brings things together. External events combine with internal pro-
cesses, subjective impressions merge with objective processes, and ear-
lier time frames blend with later ones. Symbols are characteristically
multileveled (Kreitler & Kreitler, 1979), simultaneously containing
many meanings and interpretations. Jung (1966) described a “bipolar”

therapeutic potential in the symbol. He viewed the personality as being
built from opposing forces and polarities that were continually threaten-
ing the whole. The appearance of the symbol in the client’s world
served as a unifying factor, becoming a counterweight for polarized
forces and contributing to the personality’s stability and balance.
Visual symbolism arising in PTSD sufferers’ artwork enables them
to cope in a way more suited to the trauma’s nature, a way that is neither
linear nor verbal (Johnson, 1987). When a symbol appears in a client’s
work, it contains the complexities of fragments of memories, sensa-
tions, colors, and shapes that link the various events and periods of the
client’s life. When this process occurs, the client begins to encounter in-
ternal, separate and dissociated parts, and can create a dialogue between
these parts to foster integration and new reconstruction of the personal
narrative.
The symbol that is expressed on paper as a work of art enables the cli-
ent to distance him/herself from the traumatic materials (Cohen et al.,
1995; Johnson, 1987). The client has the power to make changes in the
symbol, omit parts, and/or recreate it, etc. This ability to change the
symbol leads to a greater sense of control over the traumatic experience
itself, and begins to create the rectifying processes of healing.
Changes in symbols can also lead to behavioral changes (Cohen et al,
1995). Changing artistic images is easier than to change behavior pat-
terns or life conditions. However, the experience of making changes in
artwork can facilitate the onset of reorganization and generate life
changes. Golub (1985) described her work in which symbolic expres-
sions appearing in the artwork of Vietnam combat PTSD sufferers in-
fluenced her clients, helping them to successfully view their problems
in a different manner and discover alternative solutions. While working
Dalia Avrahami 11
with symbols can expose clients to suffering, the soul also creates
symbols that show the path to healing (Levine, 1995).
Containment, Transference and Countertransference
Containment
Art therapy offers a unique, multi-faceted mechanism for contain-

ment in work with PTSD sufferers. First the visual art medium is a
concrete vessel with boundaries, e.g., the borders of the paper, the boun-
daries of the sculpture. This vessel can concretely contain the inner cha-
otic, fragmented, unanticipated, and amorphous traumatic experience

within. Suffering is given a shape: “The task of therapy is not to elimi-
nate suffering but to give a voice to it, to find a form in which it can be
expressed” (Levin, 1995, p. 15). Secondly, within the artistic medium, a
containing symbol can appear, providing a boundary for a wide spec-
trum of events, associations, times and sensations, and enabling the
containment of all of the events that are beyond words. This visual con-
tainment enables clients (Knill, Barba & Fuchs, 1993) to go within
themselves during the creative process, yet keep distance by observing
their handiwork. Passing from an internal reality to an external one fa-
cilitates the controlling of the process, which is one of the most impor-
tant achievements in work with PTSD sufferers.
Transference
The complexity of transference and counter transference in work

with PTSD victims has been widely discussed (Herman, 1997; Johnson,
1987; Lindy, 1989; Noy, 2000; Shalev, 1991). Herman (1997) notes
that patients suffering from PTSD create a special type of transference
in their therapeutic relationship reflecting two harsh experiences: terror
and helplessness. This experience has almost no parallel in “regular”
therapy. The transference developed by a PTSD client has two extreme
polarities that reflect trust and distrust. While the helplessness experi-
enced in the trauma creates a desperate need for an omnipotent savior,
experiencing terror creates an extreme lack of trust in people. Herman
claims that frequently the client transfers these emotions on to the
therapist–ranging from the idealization of the therapist as the all power-
ful protector to the complete distrust of the therapist reflected in the
client’s total lack of desire to cooperate.
Researchers (e.g., Johnson, 1987; Schaverien, 1995) maintain that art

therapy eases the potentially intense client-therapist relationship by cre-
ating an external concrete transitional arena, which becomes the central
focus of projected emotions. The artistic image, which is brought by the
patients, serves not only to express the patient’s feelings, but also repre-
sents a mediating element between him/her and the therapist. With the
help of the image, the patient makes a statement about the self–but also
makes a statement that is aimed at the therapist. The image may func-
tion in various ways: it can be discarded, destroyed or preserved. The
patient may do what he wants to the image, and communicate through it
to the therapist in an indirect manner.
Countertransference
A mental health professional treating a post-traumatic patient is in-

fluenced by various processes, which might alter his attitude toward the
patient (Lindy, 1989; Shalev, 1991). The boundaries are vaguer and less
clearly defined in countertransference than in other disorders. The fact
that very often both the patient and the therapist have been exposed to
the same historic events (i.e., the Holocaust, wars, etc.) determines not
only the patient’s identity, but also that of the therapist. Therapists must
absorb and work through their own personal reactions with their attitude
towards the survivor-patient. Relating to the client though artwork en-
ables the therapist to generate a dialogue through a mediating and
symbolic element that facilitates the therapy and eases the countert-
ransference responses.
In the following two case studies I examine how each client uniquely
expresses the processing of traumatic memories, symbolization and in-
tegration, containment, transference and counter transference. The first
client, having no prior therapy experience, needed to pass through form,
line and color development to reach the trauma core and relate to it in a
manner appropriate for him to reach a measure of balance. The second
client worked with one symbol that developed during the therapeutic
process, and indirectly and non-threateningly reconstructed a biograph-
ical narrative.
ART THERAPY WITH VICTIMS OF PTSD
To understand and accept the path each client traveled, the basic as-
sumptions associated with art therapy and the stages of treatment must
Dalia Avrahami 13
be understood. There are three basic assumptions associated with the

language of drawings (Furth, 1988) and one additional basic assump-
tion pertaining to art materials (Cohen et al., 1995; Kagin & Lusebrink,
1978):
1. The source of drawing is the unconscious.

2. Artwork reliably reflects processes whose source is the uncon-
scious. Isomorphism or correspondence exists between the inner
attitude and its external declaration.
3. Changes in artworks, images and symbols reliably reflect pro-
cesses of change the client’s everyday life.
4. The choice of art materials reflects the client’s place in the thera-
peutic process. There is a differentiation between easily controlla-
ble materials and materials that are difficult to control. Use of
controllable materials such as pencils, colored pencils, markers,
or picture collages generally reflects defensive processes and fear
of loss of control. Use of fluid materials, which are harder to con-
trol, such as water colors, gouache, or acrylic facilitates access to
emotions. Using these less controllable materials generally occurs
later in therapy and reflects a departure from defenses and flowing
with the emotions that ensue.
Art therapy for PTSD must also follow the standards of stage ori-
ented treatment. The four principle stages of work with PTSD sufferers
are (Herman, 1997; Noy, 2000; Stronach-Buschel, 1990):
1. Generating confidence and control.

2. Processing traumatic memories.
3. Working on emotions.
4. Rejoining the world.
The Therapeutic Framework
The therapy sessions described in this article were held at a rehabili-

tation center for PTSD victims of battle-shocked patients. One-hour art
therapy sessions were held each week for each client for a six month pe-
riod. The workshop’s studio contained a rich variety of art supplies: col-
ored magazines, photographs of works by artists, various kinds of
painting and drawing media (colored pencils, markers, oil pastels,
gouache, black and colored ink), various tools (paint brushes, sponges,
paint rollers), clay, plasticine modeling clay, wooden surfaces, wooden
sticks, different types of paper, materials from nature that enable a touch
with the concrete world (leaves, branches, shells), and different kinds of
string and ropes mosaic stones. This supply enabled clients to connect
to a wide variety of memories, events and emotional situations.
The therapy session was conducted according to the client’s needs at
a given moment and generally consisted of three stages:
1. A short conversation of relevant contents brought by the client.
2. Working on an art product-frequently accompanied by talking.
3. Conversation that emerged from the artwork itself. At first the dia-
logue focused on the various components of the artwork created:
line, shape, color–which enabled clients to distance themselves
from the intensity of what emerged (Betensky, 1995). As the con-

versation deepened, a connection frequently began to form be-
tween the components of the artwork and the internal experience.
Giving the work a name enabled verbal articulation of symbolic
expression.
Corresponding to the approach that imparts control of therapeutic
process to the client (Herman, 1997; Noy, 2000; Stronach-Buschel,
1990), the principal role of the visual art therapist is facilitating the for-
mation of the natural creative process. In the therapy sessions described
in the case studies below, clients were enabled to find their own way, in
their own time and rhythm. They chose art materials appropriate for
their needs. They chose to speak or remain silent while working. If they
experienced extreme difficulty, they could leave the studio therapy
hour. All these approaches were aimed at helping clients sense that
things were not arbitrarily forced upon them. Throughout, I placed my
trust in the clients’ natural, creative resources to reveal and help them
along the healing path (Furth, 1988; Jung, 1966; Levine, 1995). As an
art therapist, my intervention in the therapeutic process was predomi-
nantly through exposing my clients to the art supplies in the room, and
to tools and work techniques. The conversation on elements that ap-
peared in the artworks empowered them to either bring forth or conceal
the traumatic materials and thus control them (Betensky, 1995; Cohen &
Cox, 1989).
The case study descriptions below present a combination of the cli-
ents’ verbal exchanges, references from the literature, and my retro-
spective view based on the development of the creative process and
changes experienced by the clients outside the therapy hour. The ac-
companying photographs reflect the majority of the clients’ artwork.
Permission from both clients was obtained to publish their stories and
artwork.
Dalia Avrahami 15
CASE STUDY 1–H. “EMERGING FROM THE CLOSET”

H., a 65 year-old man, suffered from PTSD following the Six Days
War, although it was not diagnosed at the time. He suffered an addi-
tional trauma during the war in Lebanon and had not been able to work
since that time. The degree of his handicap was not determined for
many years; he was primarily defined as having a physical handicap. H.
lived alone, cut off from his family, in poverty. He was never afforded
the opportunity to talk, treat, or process the trauma. Most of the time H.
would come to sessions willingly, although sometimes when in a state
of confusion, he would say that he didn’t feel well and didn’t want to
come to the session. He often found it difficult to begin the creative

work, claiming he lacked ideas. He would state that he wasn’t talented
and didn’t know how to draw. However, after I would spread out a vari-
ety of materials in the room, he would slowly connect with a particular
material and begin to work. He was very open working with materials
and tools, displaying originality and innovativeness.
Seven different stages could be discerned in H.’s work.
Generating Confidence–Figure 1
H. chose to render a closet at the first session. Constantly busy with
measuring, he worked exactingly with a pen and ruler. When he worked
FIGURE 1. Pen on paper, 35 cm ⫻ 50 cm.
he said, “That’s the way I always began to work when I was a carpen-
ter.” H.’s past carpentry work was the center of his life. He had not
worked since the Lebanese War because of physical and emotional lim-
itations.
H. began art therapy by producing a spontaneous image, a known
safe image in his life, an image that enabled him to be in a consoling
place of control and safety (Herman, 1997; Noy, 2000), a place where
he had a high self-image and a professional image.
Gradual, Slow Exposure of the First Trauma–
Figures 2, 3, 4, 5
From the second session H. began a process of emerging from this

closet. The gradual unveiling of the closet’s contents produced separate,
traumatic, dissociative fragments from his life until H. reached the core
of the initial trauma. Figures 2, 3, and 4 revealed traumatic fragments
from the client’s past and present. The starting point for each work was
the precise drafting of a frame on the paper using a pencil and ruler. In
the artwork, the closet opened, revealing the inside; the frame remained
for containment and protection. As the client felt safer, more confident,
the frame gradually disappeared from his work.
Figures 2, 3, and 4 each contained a frame, image and background.
Lengthwise or widthwise wavy lines in blue, red or grey composed each
background. An element or figure symbolizing a traumatic fragment
FIGURE 2. “Whirlpool.” Pencil and oil pastels on paper, 35 cm ⫻ 50 cm.
Dalia Avrahami 17
FIGURE 3. Pencil and oil pastels on paper, 35 cm ⫻ 50 cm.


was placed in the center of each. In Figure 2, “Whirlpool,” referred to an

experience of near drowning that H. survived during the period between
his military traumas. In Figure 3, a split image appeared–a figure in
which the head and body were disconnected–cut off from one another.
In reference to Figure 4, H. spoke of a close friend who was badly
wounded, and of nightmares connected to seeing body parts flying in
the air at the time of the traumatic event. H. had collected body parts in
cartons, and incidentally mentioned that the size of the cartons was very
similar to the size of the sheet of paper on which he was drawing at the
time.
The wavy lines surrounding the central element in these three works
contain bipolar symbols (Jung, 1966). Although H. said they symbol-

ized pleasant softness–sea and cotton fields, further on in the conversa-
tion, their opposite nature was disclosed. Although H. loved to gaze at
the sea because of its calming effect (the blue lines in Figure 2), since
the event in which he almost drowned, he avoided entering the water.
The wavy red lines in Figure 5 represented the cotton fields of Kib-
butz Nahal Oz. H. loved to look at them. However, these same soft and
relaxing cotton fields became an all consuming inferno for those ex-
posed to the bombardment that transpired there during the “waiting pe-
riod” before the Six Days War.

Dalia Avrahami 19
The gradual reference to these traumatic fragments, the complexity

of the background and foreground symbols and their containment
within the closet structure–the client’s safety container, enabled him to
emerge from the closet and reach the core of the initial trauma saying, “I
have been dreaming about painting the event that I endured for a long
time and now I want to try.”
The painting of the trauma, as reflected in Figure 5, expressed the
“photographic memory” associated with traumatic events (Johnson,
1987), containing precise details of the appearance, time, feelings and
sounds. H. felt confident conveying these onerous events, no longer
needed to draft a penciled frame within the painting. In H.’s words,
“The small house on the right is Kibbutz Nahal Oz where we were sta-
tioned during the ‘waiting period’ before the outbreak of Six Days War.
On the upper right is a tree–the grove where we were stationed. In the
upper left was barbed wire, that’s where we tried to break through–and
then they told us to return.” As he related this, H. continually mumbled.
“The Burma road, the Burma road.” Perhaps this was a password trans-
mitting a specific message to them at the time and as he worked he be-
gan to hear the sounds.
H. continued, “The four automobiles on the right are four command
cars that ordered the mission to pass over the hill and invade Gaza at all
costs. We were cannon fodder. The lines are like red and blue waves. It
is the cotton fields of Nahal Oz. There was a demilitarized zone between
the hill and fields, which caught fire and people burned. We were unable
to breach the hill and we were fired upon. The sun’s glare was blinding,
the enemy saw us and we didn’t see them and many people were killed.”
H. was wounded lightly during the shelling, but his good friend was
seriously injured. H. was in shock and was hospitalized for a time. He
visited his friend around the time of his injury, but he hadn’t seen him
since then, and had no idea what happened to him. He had strong guilt
feelings that he didn’t protect him as they had promised each other
while they were waiting. After H. introduced this burdensome content
from the closet, the other polarity of the symbol’s representation was
displayed and he encountered parts of the closet’s positive representa-
tions as he revealed a sense of humor. H. told stories related to digging
foxholes at the time and elaborately recounted how everyone wanted to
be with him in his foxhole because they knew that he put in a lot of work
into it, building shelves and other things a professional carpenter knew
how to do. He laughed a great deal as he depicted these events.
Working on Emotions–Loneliness–Figure 6
H. felt sufficiently confident to introduce emotions, which were re-

flected in the form and content of his artwork–the images that emerged
and the manner in which they were rendered. H. began to abandon the
complete pencil frame form as his technique for opening each work ses-
sion. He left the easily controlled art materials and moved on to the
more fluid materials: plasticine, smearing oil pastels, gouache, and
color roller (Cohen et al., 1995; Kagin & Lusebrink, 1978).
H. called the work in Figure 6 “Rainbow and Clouds.” The work was
made with crude, expressive smears of plasticine, his hands in direct
contact with the art materials and work surface. The work process had a
sense of a great emotional investment. The principal emotions arising
from the artwork were loneliness and suffocation. The rainbow symbol
emerged containing bipolar significance (as it was interpreted), protect-
ing as well as suffocating him. H. was a solitary man, disconnected from
family and friends.
Raising the Second Trauma–Figure 7
When H. rendered his life’s second trauma on paper he felt again in

need of protection–hence, the return of the pencil and ruler drawn closet
FIGURE 6. “Rainbow and Clouds.” Gouache and plasticine on chipboard, 25

cm ⫻ 35 cm.
Dalia Avrahami 21
FIGURE 7. Oil pastels on paper, 35 cm ⫻ 50 cm using hands to smudge colors.

frame in the work in Figure 7. Different techniques were used to depict

this trauma than those chosen to express the first trauma.
The work was rendered using unconstrained, rough, imprecise smears
of black oil pastels (the upper part) and blue (on the lower area). The ex-
pression had an expressive emotional quality rather than the descriptive
graphic character chosen to convey the first trauma. A human image be-
gan to emerge in the work’s center containing head and body according
to conventional proportions.
He related that this work described the hospital stay following his
second injury during the war in Lebanon. During this period he under-
went many surgical operations and remained unconscious for quite a
long time. H. said that he didn’t understand what he painted; perhaps it
was the fog that engulfed him during that period.
Working on Emotions–Missing Out–Figure 8
H. chose a mixed media technique for the work in Figure 8–smearing

gouache paint, working it over with a paint roller and even integrating
his work with a paintbrush.
This work marked a turning point the therapeutic process, which was
displayed in the means of expression. The location of the black and blue
colors found in the previous work (Figure 7) was reversed. The fog that
FIGURE 8. Gouache on chip board, 35 cm ⫻ 40 cm using paintbrush and paint

roller.
dominated the upper area of the previous work was dispersed and things
appeared with greater clarity. There was a certain feeling of the sky
clearing after the rainbow appeared. For the first time in his work, a hu-
man image appeared with all body parts clearly visible, in a proper pose
and with reasonable proportions. The black ambiguous, confused hu-
man image from Figure 7 was transformed into a more optimistic white
image. Five stars and the sun appeared in the sky (according to H.) fore-
shadowing the five significant circles that would emerge in his next
work.
The primary feeling that H. raised was one of “missing out.” H. loved
his artwork, and it surprised him that he was able to paint so beautifully.
However, it simultaneously evoked a heavy feeling of what he missed–
that he never had the time to study and advance himself. H. allowed
himself to mourn his life–a marriage at an early age that quickly deterio-
rated, failure to realize his potential, and the traumas’ domination over
his life.
Between the two extremes of aesthetic beauty and the feeling of
missed opportunities, a third position was created–a kind of balance be-
tween them, a balance of hope. H. observed his work and verbalized the
hope that perhaps now a new horizon was opening for him. He called
Dalia Avrahami 23
the ladder appearing in the work, “Jacob’s ladder with angels climbing
and descending.” Ladders appearing in clients’ drawings (Ankory,
1991; Cirlot, 1995) frequently indicate the awakening of hope, and of
deliverance from the existing situation.
Reassessment of His Relationships with the World–Figure 9
H. began the work in Figure 9 by painting five circles at the bottom of

the paper saying that he thought of five things that he wanted to open but
wasn’t successful. In earlier sessions he related that he had five children
from whom he had been estranged for many years and that he wanted to
understand the rift that was formed. As he talked about the artwork he
did not understand the significance of the five circles nor was he able to
connect them to his life. Observing his work, H. said that he really liked
the central diagonal row with the five yellow circles appearing in an or-
derly fashion, equidistant from each other. Without forming a verbal in-
sight, hope awakened in H. through his artwork for a relationship and a
new order with his children. H.’s artwork spoke of the disarray of the
past 30 years and his wishes to put some order into his life. He used
many colors in this work with the color black seeping into the spaces
inbetween.
Integrative Processes and Discovering Sources of Creativity

and Empowerment–Figure 10
In the work in Figure 10, H. encountered the colorful origins of his

life. H. used a multitude of colors and various printing techniques of his
own invention giving the work a very personal stamp. As he worked,
childhood memories emerged concerning the place where he was born.
He related that when he was a boy he looked at the mountains and
thought that there were many colored papers behind them. He used the
same colors as a source of creativity, a source of power. In this work H.
painted the memory of the colors of his childhood. Contrary to earlier
works, the color black didn’t take over this work. He captured some of
the colors that characterized him at this moment of his life. A kind of
balance was formed among the colors reaching a new equilibrium.
An accord between form and content can be seen in the process H.
experienced. The development of the character of line in his artwork re-
flected the course of the therapeutic process. Betensky (1995), on dis-
cussing the symbolic expression of the line, observes that wavy lines
FIGURE 9. Gouache on chip board, 70 cm ⫻ 50 cm using techniques of

sponge printing, paint roller and paintbrush.
indicate confidence and calm. In H.’s work (see Figures 2, 3, and 4)

wavy lines appeared, occupying most of the paper’s area–H. stated that
they represented a calm place in his life. Perhaps the wavy lines at the
outset of the therapeutic process were an indication of his confidence in
Dalia Avrahami 25
FIGURE 10. Gouache on chip board, 70 cm ⫻ 50 cm using varied print tech-

niques, tissue paper and hands.
therapy, or perhaps they reflected his aspirations for a place of this kind,
or perhaps that he brought memories with him of a calm and peaceful
inner place that enabled him to evoke the traumatic fragments. Possibly,
the symbol had simultaneous multidimensional meanings of all of the
above.
In the works shown in Figures 6 and 7 the rainbow arch shape domi-
nated the center. Betensky (1995) suggests that this shape indicates
melancholy and mourning, and, indeed, these emotions were character-
istic of the client at this stage of therapy.
The line that characterized the work in Figure 9 was a row of diago-
nals from the left side of the work to the right. Betensky (1995) attrib-
utes the appearance of such lines in art therapy products as signifying
motion–a sense that the client is beginning to move, which indeed, ap-
propriately characterized H.’s situation in the therapeutic process de-
scribed. According to H., even at this late time in his life, he was
afforded the opportunity to tell his trauma, something he had wanted to
do for a long time. Working on the trauma in an appropriate manner
cleared space for additional facets in his personality to come forth, en-
abling the forgotten healthy aspects like humor, joy, and colorfulness to
reappear. H.’s works made a transition from frozen, exacting, graphic
work in pencil to the expressive articulation of hand smeared color. In ad-
dition, the progression showed activation of many parts of the body, en-
abling him to begin connecting the head-body split (Figure 3) and to
relate to his feelings. The art therapy allowed him to return to the origins
of creativity from his childhood, which gave him the strength to keep cre-
ating. H., in his mid sixties, was immersed in aimless idleness, lacking so-
cial relationships for many years. At the conclusion of the art therapy
sessions, he verbalized a wish to do something, to create, to enjoy, to en-
gage in art and make plans for the future. He tried to reestablish his rela-
tionship with his children and in addition asked one of his sons to search
for information about his good friend who was wounded in the bombard-
ment during the Six Days War. Helplessness gave way to action.
CASE STUDY 2–R. “A DREAM VACATION ON THE WATER

AT A PERSONAL PACE”–THE BOAT SYMBOL AND ITS
DEVELOPMENT IN A PTSD SUFFERER’S ARTWORK
R., aged 58, suffered from PTSD following the Yom Kippur War. He
had been hospitalized several times throughout his life. During periods
of remission, he worked and managed a factory. His condition deterio-
rated in year preceding his art therapy and he ceased working. For many
years he had been treated with medications. However, there had been a
period when he underwent very significant therapy and he had stopped
taking medication for about five years.
R. loved to come to the therapy hour and had a hard time leaving. He
worked spontaneously, rapidly connecting to the materials. Occasion-
ally he planned the continuation of a work at home and brought materi-
als to support his ideas. From the first session R. began working
spontaneously on a boat image. Using a collage technique of photo-
graphs chosen from magazines, R. called the work: “Calm Place” (Fig-
ure 11). Containing three separate pictures, the work introduced the
conflict of the trauma sufferer in a basic manner: memory versus amne-
sia, flooding versus avoidance (Herman, 1997). In the bottom left pic-
ture, a flood with a powerfully flowing waterfall appeared. In the top
left picture, all was frozen, at a standstill: an empty harbor, boats tied
one to the other with no movement. A symbol appeared on the right–
from top to bottom, unifying the two conflicting representations. A
Dalia Avrahami 27
FIGURE 11. “Calm Place.” Collage of magazine photos on paper.

yacht appeared–the boat is not tied, nor is the current raging. The boat
appeared to sail in calm waters, establishing unification and balance.
During the art therapy work, movement was created to repair such a
split–the mind looking for and discovering the balance (Jung, 1966).
Frequently, therapy is perceived as departing on a journey. This cli-
ent departed on a therapeutic journey and used images that emerged
spontaneously to speak to himself as well as to the therapist–as in the
upper right hand corner of this picture where “Dream vacation on the
water at a personal pace” is written like an advertisement for a product.
According to R., he had a personal dream fantasy of a trip. Throughout
the therapy he emphasized his need for his own personal time, that there
was no rush, and that he wanted to repeatedly repair and strengthen the
boat, his chosen vehicle for the journey, making sure it would be ready
and able to make the trip.
At the outset of work on this image, R. had evoked feelings of oppo-
site polarities (Jung, 1966): positive memories from the past as opposed
to present feelings of sorrow and loss. Years ago, he had a boat of his
own and would sail with his family along the Israeli coast. With his
emotional and economic deterioration, he was compelled to sell the
boat. He had a dream to sell everything, purchase a new boat and sally
forth on a never-ending journey at sea with his wife.
In the next sessions R. turned to another material, clay, to create the
work in Figures 12 and 13. He said that he loved clay because of its con-
FIGURE 12. The Boat, made of clay and assorted materials.

nection to the earth. The transition to working with clay enabled him to
reach a very primal, regressive place (Kagin & Lusebrink, 1978). He
had the opportunity to build an image as something that approached re-
ality and subsequently enabled him to realize a dream.
In the initial stages of his work with clay, H. repeatedly examined the
material’s suitability as a vessel for the present journey. Cracks ap-
peared in the boat during the work process, caused by the drying process
of the clay, and led to questions of trust and distrust in the therapeutic
situation (Herman, 1997). At first he would ask me if I had enough
knowledge about working with clay. Using the art material as a media-
tor, he was able to raise questions related to me that perhaps he would
not been able to raise otherwise (Johnson, 1987). In the wake of his
doubts about the materials he spoke of different materials used for ship
building in the past such as wire netting and concrete, wood and fiber-
glass. When surveying the various materials he vacillated between trust
and distrust in their strength and durability.
Slowly, memory from distant days burst forth–memories that he
claimed hadn’t arisen until the therapy: the drowning of two childhood
friends who went on a boating holiday together when he was 16. This
Dalia Avrahami 29
FIGURE 13. The Boat, made of clay and assorted materials.

revelation was a surprise for him; however, the art therapy framework
enabled him to contain and assimilate the remembering and information
without a sense of being overwhelmed (Cohen et al., 1995; Kagin &
Lusebrink, 1978).
We generally held a verbal dialogue through the image (Betensky,
1995). We spoke of the components a boat needs to be sea worthy, the
route it would take, the stops along the way, etc. When we would con-
verse using the image, R. would occasionally have a half smile, as if it
was clear to both of us that while we were talking about the boat, we
were really talking about something else. The multidimensional com-
plexity of the symbol fostered a dialogue of multiple meanings. Speak-
ing of himself through a mediating factor, through the boat, greatly
facilitated the therapeutic process, transference and countertransfer-
ence.
Much creativity accompanied the work R. devoted to the boat and the
time spent with the symbol. The more R. invested in it, both physically
and emotionally, the more the symbol fostered encounters with signifi-
cant contents. R. added masts and a rudder; the slowly executed work
continued over several sessions. He tested different materials until he
found the proper ones. He created nooks and niches, attempting to sub-
stitute different materials.
R. created the rudder working with great preciseness and a calm he
said he had not felt in a long time. The work on the rudder, the instru-
ment that was supposed to steer the boat, led to disclosures of memories
from the distant past, memories that were pertinent to his family and
himself over different periods of time. These memories were mostly
amusing and entertaining and made him laugh.
Through the painstaking work on the masts, he encountered memo-
ries that enabled him to return to a place of feeling and emotion. In his
youth R. performed mechanical work that necessitated considerable
precision, and was subsequently as meticulous and exacting in every-
thing he did. R. expressed deep regret that he was forced to stop work-
ing and also that due to the physical limitations caused by long-term use
of medications, his current precision was not like it was in the past.
When he began to connect the masts with ropes, he remembered a
childhood event of flying kites. He related that the kites were tied with
string identical to what he used to connect the masts now. R. remem-
bered many mischievous deeds tied to kite flying. R. allowed himself to
return to that place and the enjoyment of his inner child and imagina-
tion.
While he was working on the sails he acquired carpentry tools and
said he had planned to try to reestablish a workspace at home.
The image of the boat, the materials, the details it comprised and the
punctilious nature of his work began to connect and link events from the
different periods of his life to create a biographical sequence. Each time
doing the artwork evoked more distant memories until it reached the
places of joy and spontaneity, places of substantial strength–places
from before the trauma. The present connected to the past and created a
bond of hope and future plans.
After the prolonged work on the boat, reinforcement and finish of the
vessel, R. first told me his life story verbally; it was a story with linear
continuity, chronological order with an emphasis on the core pain. He
didn’t tell of the trauma, but rather he told of the trauma of life after the
trauma, of repeated hospitalizations, amnesia (including reading and
writing around the time of the trauma), and the sense of painful aban-
donment by society. R. had succeeded in rehabilitating himself to some
extent, and returned to the work force, but every once in a while went
through a crisis period. A year before the therapy he had a “breakdown”
and left everything. R. allowed himself to mourn, to express deep sor-
Dalia Avrahami 31
row for his life and for his family life that was disrupted from the begin-
ning due to the trauma. The artwork connected him to his life at the
present–creating a bridge between internal and external, between fan-
tasy and the attempts at partial fulfillment–which had many ramifica-
tions on his life. While R. was creatively building the boat, he took a
sailing course that gave him much joy, a course that gave him a sense
that life was beginning to move again.
R. passed through three stages while working on the boat:
1. Creating the inner space for the symbol as he allowed himself to re-
construct the symbolic abilities that were injured (Herman, 1997;
Stronach-Buschel, 1990; Van der Kolk, 1994). R. built a place of

anchorage and calm, a place of balance, unification and integration
of conflicting forces at play within him (Herman, 1997).
2. Memory work. From the secure place he created, R. enabled him-
self to touch difficult portions of his life such as loss, anger, and
mourning. As a result, dissociated fragments of memory began to
associatively connect to a safe, whole, concrete image (McNiff,
1975). The bipolarity of the symbol (Jung, 1966) brought the suf-
fering in his works to a place of healing, to good and forgotten
places, places of spontaneity and creativity that greatly empow-
ered him (Levine, 1995).
3. The symbol became a bridge between inner life, aspirations and
fantasies, and reality outside the hour of therapy, which in turn led
to a place to begin renewed growth. He began to participate in the
sailing course that enabled him to dare to confront the outside
world again. Experiencing precision manual work during the art
therapy reinforced his confidence in the healthy parts of his past.
He rebuilt a workspace at home, and purchased new tools, while
hoping to try to return to work at a modest pace.
DISCUSSION
These case studies illustrate the contribution of art therapy in the
three areas mentioned above.
Processing Traumatic Memories
Both clients described suffered from chronic PTSD: H. since his in-
jury in 1967 and R. since 1973. Their first exposure to art therapy and
working through art was with me at the Tel HaShomer Hospital Work-
shop for battle shock PTSD victims. Art therapy enabled the traumatic,
dissociative and repressed material each had stored as unconscious sen-
sory and photographic memories to reach consciousness. Chaotic, over-

whelming memories found a concrete expression in the artwork, creating
a safe space with clear borders that facilitated the reconstruction and
processing of the traumatic experience.
H. unveiled memories of two central traumas in his life (that of the
waiting period before the Six Days War, and the second during the war
in Lebanon) and R. reached the most painful place for him–the trauma
after the trauma. The variety of art materials and their choices enabled
them both to express emotions connected to these memories: sorrow,
confusion, depression, anger and missing out.
Both clients were able distance themselves from the trauma through
their artwork. One approach that facilitated this process was using sev-
eral perspectives simultaneously in a particular artwork. In H.’s work
(Figure 5) several different perspectives can be distinguished. The less
traumatic portions, associated with the pastoral segments, before the at-
tempt to charge the hill (the house–kibbutz, tree–grove), appear in nor-
mal perspective. The traumatic sections connected to the attack on the
hill (the command cars, the fields, the hill) are seen from a bird’s-eye
view. Creating this perspective enabled the client to create a distance
between himself and the events and reassess them without emotional
flooding. One can see that a great deal of work had been put into the sen-
sitive coloring of the brown form on the left side of the drawing, the hill,
using smearable oil pastels. This work enabled H. to experience strong
emotion while at the same time, keeping his distance.
There was also a use of words in the drawing; H. wrote in Hebrew:
“demilitarized zone” in an “empty” area between the fields of the kib-
butz (blue and red lines) and the hill (brown form). This was the most
traumatic place for the client, the place where the field of bramble and
thorns caught fire and people burned trying to charge towards the hill.
Frequently, text additions in a work of art express the client’s apprehen-
sion that the artwork may not be fully understood by the observer. How-
ever, it is possible in this case that the anxiety surrounding this place
was so great he waived his expressivity in advance and preferred to use
only words.
With R., the perspective phenomenon is seen through the viewpoint
of photographs chosen for his collage. The upper left photograph sym-
bolizing a frozen situation was photographed from a normal perspec-
tive. In contrast, the flood picture (on the lower left) and the photograph
of the ship sailing (center) were taken from an aerial view. Flooding and
movement are very frightening to someone in a frozen state. This pic-
ture is first work of the client, a work that revealed the central conflict of
the trauma–the flooding versus frozen state. The choice of pictures en-
Dalia Avrahami 33
abled the client to unconsciously create a distance between him and

traumatic materials that arose and were finally expressed through art.
The fear of moving forward was reflected throughout therapy. And in-
deed, during the therapy the boat did not move. It was on a journey
backwards in time. When this journey was completed, plans were made
for future trips and realizing his travel plans commenced with the cli-
ent’s participation in a yacht sailing course.
Processing the memories also fostered the surfacing of positive life
memories, which enabled them to look at life in a new light. Each client
began to release his particular trauma from isolation and commenced
the process of integration into his personal biographical continuity.
Symbolization-Integration Process
The artwork enabled both clients to be in a symbolic space connect-

ing their inner and outer worlds, a space where anxiety decreases and
the processing of difficult contents is eased. Spontaneous symbols sur-
faced in the artwork (H.’s closet, ladder, six stars, five circles; R.’s boat
with all its parts and accessories) containing references to other events
and times. The distance between the clients and the symbols they cre-
ated eased the encounter with their separate, dissociated parts.
In this same way, symbol development enabled the reconstruction of
the biographical sequence. H. was able to symbolize the location of the
first trauma and express it concretely in his artwork (Figure 5). R., using
the symbol of the boat and its parts, facilitated a dialogue and revela-
tions regarding more difficult things from the past. This creative mode
helped them both begin the formulation of a whole, continuous picture
of their life’s course: a picture containing the good and the bad, yet with
a new potential to reconnect to their lives.
Transference and Countertransference
Transference
For both clients the central feeling of trauma victims surfaced through
transference: helplessness and trust versus lack of trust. The artworks
facilitated a change in these feelings. H. brought feelings of helpless-
ness: “I don’t know how to draw or what to do,” and “Tell me what to
do.” Towards the end of the therapy, he spoke about his present rela-
tionship with his mother, a woman of 90, whom he visits when he is un-
happy and in need of comfort. H., who to his accounts, was deserted by
his wife and children, succeeded through transference to internalize the
significance and existence of the dependent mother–child relationship

that he had with his elderly mother and tried to examine what went
wrong with his relationships with his own family through his artwork.
R. would tell his grandchildren (so he told me) that he has a “nursery
school teacher” that he works with. When he spoke with his grandchil-
dren at a level they understood, he expressed his feelings of transfer-
ence, of the little, helpless boy looking for a nursery school teacher to
guide him. On the other hand, through his work on the boat the clay that
dried and the cracks that were formed in the boat brought forth feelings
of trust in the therapy. Questions that arose, such as, “Do you have
enough experience working with clay?” allowing him to express his
doubts and which might not have been able to surface otherwise.
Through transference, both clients reached the primary place of a small
child’s helplessness, yet, they also reached colorful places of childhood
and memories of freedom and play. They reached the primeval place be-
fore the trauma from which they could draw strength for creativity and
action in the future. As suggested by researchers (e.g., Johnson, 1987;
Scaer, 2001; Van der Kolk, 1994), when trauma occurs, adult, cognitive,
verbal and linear coping tools are bypassed, and the victims return to the
primary chaotic place of sensations, feelings and pictures. Through trans-
ference the clients were able to stay in this place, process it and gather
strength from it to pass into a more adult stage of coping.
Countertransference
The artwork of both clients dealt with the traumatic reality that every-
one living in Israel is exposed to and experiences–the reality of war and
its accompanying psychic damage. H. dealt with the reality of the Six
Days War and the war in Lebanon; R. was immersed in the Yom Kippur
War.
In the Yom Kippur War, I experienced personal loss and in the en-
counter with R., intense feelings surfaced that I needed to face. Process-
ing R.’s traumatic materials through his artwork made it much easier for
me. We were busy with the process of constructing a boat and planning
the outset of a journey. The trauma indirectly permeated the doing of it.
About two years after the Yom Kippur War, during my own psycho-
therapy, I dreamt that I was boarding a boat that was ready to sail, wav-
ing goodbye to people standing on the beach. This memory and the
personal processes that I experienced gave me the strength and opti-
mism to help R. sail on his own personal journey.
Working with H. was exciting and edifying. During the therapy I
sensed the hope that it was not too late to give him other options, despite
Dalia Avrahami 35
all the suffering he endured, a window through which he could encoun-

ter his natural talent and find uninjured places within. Encountering
these places enabled H.–despite his advancing age to begin to open a
new view on life and experience faith.
Experiencing the contribution of art therapy to the treatment of
post-traumatic problems eased my confrontation with countertrans-
ference processes that surfaced as difficult contents emerged in the
artworks.
SUMMARY
This article is based on research and work that investigates the differ-
ences between the way people experience traumatic memories and the
way they experience normal memories. Normal memories are automati-
cally integrated into a personal narrative semantically and symbolically,
without conscious awareness of the process. In contrast, the nature of
traumatic memories is dissociative, and they are stored without sym-
bolic and semantic components, as visual sensory fragments, emotional
attitudes and fixed behaviors that are unchanged over time. Van der
Kolk (1994) suggests that treating PTSD sufferers should focus on the
search for the client’s dissociative fragments and bringing them into
consciousness to enable the client to express the emotions connected to
the memories.
Art therapy has a unique role in the complex work with PTSD suffer-
ers by providing significant treatment for dissociatived memories and
permitting the client to experience a unique integrative process. It as-
sists the change of the traumatic encoding from an isolated event to an
integrated event that is interlaced with the rest of a person’s experience,
an event that is associatively linked to thought, emotions, and other
events in a personal biographical narrative. The concreteness of work
with art media endows art therapy with a dimension nonexistent in other
therapies, a dimension that includes observation and dialogue, a second
look, comparison with things that are made afterwards, and products
that can be destroyed, preserved, exhibited, or given to individuals ac-
cording to the needs of the client.
The symbolic image spontaneously emerging in the client’s artwork
is the core of the healing process and has the ability to contain and ame-
liorate the dissociative character of the trauma. The symbol reveals and
conceals at the same time. Having no linear development, it has a
dissociative character, like the traumatic memories themselves, al-
though it does succeed in organizing the parts that compose it as a whole
image. The symbolic image presents things in a manner that is tangible,
concrete and with boundaries, giving clients a sense of order, a kind of

completeness, a sense that sees the parts stored away and contained as a
whole, protected unit within the medium of art.
The symbol sends flashes and rays to hidden places in the life of the
client and begins to create bonds and associative sequences among
them, since everything that arises relates to one thing, and that is the
whole, the symbolic image. The symbol says significant things to the
client as well as to the therapist, and enables the creation of a metaphori-
cal dialogue that goes between inner and outer, and protects against
flooding. Through this mediating factor the therapeutic situation can ac-
cess traumatic places that are almost otherwise inaccessible.
All artwork is a kind of signature, an imprint of a seal that comes

from a deep significant inner place. When clients work in art they are in
the twilight state between conscious and unconscious. May (1980) re-
fers to neurological changes that the artist experiences while creating;
the source of these changes is the cessation of the parasympathetic re-
sponses of the nervous system and the activation of the sympathetic re-
sponses. This is the neurological parallel, in his opinion, to what
happens at the time of fear and anxiety. It may be that the imprint of the
traumatic seal and the imprinting of an artistic mark come from the
same source. It may be that they have influence over each other. During
art therapy clients are exposed to additional “imprint impressions” other
than those of trauma–imprinting the mark of change, the seal of integra-
tion, the stamp of hope.
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RECEIVED: 09/24/04
REVISED: 01/27/05
ACCEPTED: 01/28/05
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Visual Art Therapy's Unique Contribution in the Treatment of Post-Traumatic

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ABSTRACT. This paper describes visual art therapy as an integrative

KEYWORDS. PTSD, dissociation, biographical continuity, integrative

Post-traumatic stress disorder (PTSD) is a psychiatric syndrome that

victims in a state of “unspeakable terror.”

THE CONTRIBUTIONS OF VISUAL ART THERAPY

1. Processing of traumatic memories.

1. Declarative memory, which is conscious, accurate, verbal and

ories and associations and to the storage of conditioned sensorimotor

Scaer assumes that although declarative memory may account for

ficantly greater activity in areas of the right hemisphere associated with

The Process of Symbolization-Integration

Investigators of post-traumatic phenomena (Spaletto, 1992; Stronach-

shape, composition and color to create symbolic images that appear

many meanings and interpretations. Jung (1966) described a “bipolar”

Containment, Transference and Countertransference

Art therapy offers a unique, multi-faceted mechanism for contain-

otic, fragmented, unanticipated, and amorphous traumatic experience

The complexity of transference and counter transference in work

Researchers (e.g., Johnson, 1987; Schaverien, 1995) maintain that art

A mental health professional treating a post-traumatic patient is in-

ART THERAPY WITH VICTIMS OF PTSD

be understood. There are three basic assumptions associated with the

1. The source of drawing is the unconscious.

1. Generating confidence and control.

The Therapeutic Framework

The therapy sessions described in this article were held at a rehabili-

from the intensity of what emerged (Betensky, 1995). As the con-

CASE STUDY 1–H. “EMERGING FROM THE CLOSET”

come to the session. He often found it difficult to begin the creative

From the second session H. began a process of emerging from this

FIGURE 3. Pencil and oil pastels on paper, 35 cm ⫻ 50 cm.

FIGURE 4. Pencil and oil pastels on paper, 35 cm ⫻ 50 cm.

was placed in the center of each. In Figure 2, “Whirlpool,” referred to an

contain bipolar symbols (Jung, 1966). Although H. said they symbol-

FIGURE 5. Pencil and oil pastels on paper, 35 cm ⫻ 50 cm.

The gradual reference to these traumatic fragments, the complexity

H. felt sufficiently confident to introduce emotions, which were re-

Raising the Second Trauma–Figure 7

When H. rendered his life’s second trauma on paper he felt again in

FIGURE 6. “Rainbow and Clouds.” Gouache and plasticine on chipboard, 25

FIGURE 7. Oil pastels on paper, 35 cm ⫻ 50 cm using hands to smudge colors.

frame in the work in Figure 7. Different techniques were used to depict

Working on Emotions–Missing Out–Figure 8

H. chose a mixed media technique for the work in Figure 8–smearing

FIGURE 8. Gouache on chip board, 35 cm ⫻ 40 cm using paintbrush and paint

Reassessment of His Relationships with the World–Figure 9

H. began the work in Figure 9 by painting five circles at the bottom of

Integrative Processes and Discovering Sources of Creativity

In the work in Figure 10, H. encountered the colorful origins of his

FIGURE 9. Gouache on chip board, 70 cm ⫻ 50 cm using techniques of

indicate confidence and calm. In H.’s work (see Figures 2, 3, and 4)