Within the topic of this thematic paper I want to explore the relevance of art within the context of its use as an intervention tool for both victims and adult/juvenile perpetrators of sexual abuse. It is my belief that art therapy is a powerful means for connecting to the emotional impact of traumatic events. One of the inherent symptoms of trauma, given the heightened anxiety or hyper-alertness is that the individual will remit one of three types of predominant responses, or varying degrees of each, and that includes: flight, fight or emotional numbing. This condition is expressed by both sexual offenders during the act and by their victims. It is not known to what degree this dynamic of flight, fight or emotional numbing has also played into the sexual offender's own traumatic pre history as a victim. Within this paper, perpetrator refers to both offenders who had a previous sexual traumatic experience in childhood and offenders who do not recall such an event.

One cannot explore the usefulness of art therapy as applies to the victim of sexual abuse and perpetrator without considering what part the brain plays in the unconscious processes of artwork. One also has to take into consideration the unconscious mechanisms of the client. Other relative considerations are the effects of denial, repression, and dissociation. It is useful for this portion of the discussion to explore briefly Braun's BASK model of dissociation and Jung's four functions of the unconscious.

It is necessary to define the term dissociation. For the purposes of this paper, dissociation implies all experiences in memory that has separated from the consciousness of the individual. Dissociation is a spectrum that runs the gamut of the simple forgetting or daydreaming to long term amnesia-like experiences. (i.e. Dissociative Identity Disorder). Braun (1988), the originator of the four level BASK model of dissociation, breaks down portions of his continuum as follows:

1. Suppression: that which we do not want to think about and consciously put aside.

2. Denial: a defense mechanism used until we have the capacity to cope through other effective strategies.

3. Repression: a coping defense mechanism caused by pathological psychological conflict.

4. Dissociative Identity Disorder (DID): a defense mechanism in which memory is unavailable and there is a disruption of identity" (Braun, 1988, pp. 5-6).

The BASK model clarifies the levels in which an individual can dissociated material. It shows four levels of functioning. These levels are in behavior, affect, sensation, and knowledge. The benefit of Braun's BASK model as it applies to offender treatment is straightforward. The treatment modality of choice for sex offenders is a combination of cognitive and behavioral therapies with relapse prevention (Freeman-Longo, Blanchard, 1998) (Cummings, Buell, 1997). These models address functioning within two elements of the BASK model, that being, knowledge and behavior (generally believed to be a function of left brain hemisphere function). It is my contention that with the sex offender, who lacks the ability to empathize (thereby inhibiting his offending behavior), and who often displays either blunt affect or limited affect (Gerber, 1994), (generally believed to be a function of right hemisphere function) would benefit by use of adjunctive art therapy. It would be beneficial to mention the similarity of Jung's four functions and its relationship to the unconscious processes of the individual with Braun's model stated above will be further explained.

Jung (1959) described the psyche in terms of the unconscious elements of humankind. He differentiated between what he called the personal unconscious which included painful, threatening experiences whether repressed or ignored, and the collective unconscious consisting of buried memories based in the ancestral past. The personal unconscious would contain repressed thoughts or feelings surrounding childhood fears, abuse or unwanted emotions such as shame or guilt. I hypothesize, as an example, that both emotions of shame and guilt was experienced by the sex offender during traumatic events during their childhood that interfered with the development of empathy. Here too we have an interesting continuum - empathy at one end of the scale and guilt/shame at the other. In order to move the client toward a healthy middle ground both emotions of shame and guilt need to be addressed simultaneously. I have observed that stress related to the emergence of these long suppressed emotions are marked by considerable resistance by the offender.

In the collective unconscious, you find the instincts and archetypes. The differentiation between the two types of unconscious (collective and personal) helps in understanding and interpreting unconscious material. This unconscious material, that is revealed in symbols and is therefore often present within the modality of art therapy. One might liken the collective unconscious as similar to projections of society and the personal unconscious being that which is more individualized to the client's personal personality and motivation (Jung, 1959).

Jung's typology theory is based on the identification of four personality functions. The four consisted of people who predominately function within the field of thinking, feeling, sensing and intuiting (von Franz, 1971). In more modern times, Lazarus (Wachtel, Messer, 1997) emphasized the importance of matching assessment and intervention based on differences in an individual's functioning in the areas of behavior, affect, sensation, imagery, cognition, interpersonal relationships and biology (Wachtel, Messer, 1997). Now note the similarity to Braun's behavior, affect, sensation and knowledge that will specifically be addressed. The individual who perceives predominately in the thinking function relies heavily on the rational and is concerned with what objects are, and their utility. The feeling function is also considered a rational function however these people are primarily concerned with determining the worth of a particular object. The sensing person relies heavily on detecting objects through sensory data, which is considered one of the irrational functions. The intuitive person is one who relies heavily on hunches or guesses about what something is, when sensory data is not available. In western society, intuition is also termed an irrational function. An individual will always have a function that will be their relative weaker point however, in pathology the individual has two or more functions dissociated to varying degrees causing an imbalance in their social and personal functioning (von Franz, 1971).

Jung pointed out that the interaction of these different functions, even within healthy relationships, with their varying ways of perceiving and communicating, often produced difficulty in their interpersonal relationships. An example would be "the intuitive person being impatient with the work-a-day practicality of the sensation type" (Jung, 1957, film). The function preferences of the individual client (i.e. sensation, intuitive, feeling or intellect) is less relevant to the overall focus of this paper. I only point out that a therapist should be cognizant that these functions are relevant to the learning style of the client (Lazarus, 1989). Where resistance does not appear to be caused by a lack of motivation on the part of the offender, it may indicate that a different approach which targets another personality function may be a catalyst toward renewed movement in treatment.

In discussing art as a motivating modality and recognizing that an individual client may have to overcome their own prejudices toward the medium used before motivation is unleashed, it is beneficial to discuss the part that creativity plays in acting as a catalyst to change. Not all theorists agree as to where creativity in art falls. Some feel it is based in pathology and others see the creativity based in a healthy response. If one were to look back historically, a case in point would be the position of both Jung and May as opposed to Freud or Adler. Both Jung and May perceived creativity to be a healthy response. Adler, although more conservative than Freud, believed creativity to be based in psychopathology. For the purpose of this paper I believe creativity to be based in both ends of the psychological health/pathology spectrum. Where creativity is motivated by the need for the individual to reach wholeness and self actualization, as proposed by Jung, both the victim and an offender will move toward balance and resolution of a particular element of the recovery process. On the other hand, where the creativity is motivated by psychopathology we will see the individual (victim or offender) address that which is just below their conscious level of retrieval. The thought process originating in creativity is also based in emotional interaction. Both the states of calm and anxiety act on the chemical makeup of the brain. All of life is duality, a coming together and intermingling of opposites. Motivation can be the result of either end of the spectrum.

The process of creativity is an emotional encounter, the individual is affected by the depth of his involvement with the endeavor. It should be made clear to the client that there is a distinction between a technique of talent in art and the imaginative origin of what he creates. Creativity in an artistic modality is brought into existence by the imagination. May mentions the physiological changes which occur during intense creative encounters. He recognized a process of absorption in which the individual experiences quickened heartbeat, higher blood pressure, increased intensity and constriction of vision, a lessening of the ability to comprehend passage of time and loss of appetite (May, 1975). He stated it inhibits parasympathetic autonomic nervous system and activates the sympathetic nervous system (May, 1975). May equated this with the flight or fright reaction which occurs in fear and anxiety. I believe this to occur to an extent, but not in totality. It is too global a response. I have no doubt that this physiological reaction does occur in certain circumstances but I would clarify that it would be more likely to occur in the case of motivating factors coupled with a compulsion driven defense mechanisms. Again, I would expect this to occur in circumstances in which the art modality is focusing on the psychopathology element in of the process of the individual. It would be less likely to occur during those processes in which the individual is formulating closure and balance to a problematic area.

The brains influence on creativity as a motivating factor needs to be further explored. Language and speech, along with reasoning, are generally held in the left hemisphere brain. Up until fairly recently the prevailing believe was that the right brain was less advanced. Research indicates that both hemispheres are capable of higher functioning with each specializing in a different mode of thinking. The right brain is better with spatial problems and processes visual information. The right brain functions not only in visual modes but also in Gestalt's, is subjective, is not time-space constricted and probably is the part of the brain which processes imagination. These are all necessary processes in the process of art and the art modality. As mentioned earlier when describing Braun's BASK Model of Dissociation these are also elements that should be instrumental in accessing the area of shut down affect. Alexithymia or loss of accessibility to the emotions held by the right hemisphere is responsible for such behaviors as denial, apathy, lack of being able to read the non-verbal responses that surround us that are often used for decision making processes. It has also been reported that those who have deficits in right brain function do not have ready access to such emotions of compassion, empathy and social bonding. Without ready transfer of right/left brain influences these clients are more highly influence by the left hemisphere which functions more toward self preservation then the more social/emotional orientating right brain functions (Henry, 1993). According to Henry (1993) the left hemisphere influences coping skills such as the flight/fight/freeze response. Due to early childhood trauma individuals are in a chronic state of hyperarousal. Henry states that in studies by Davidson et. al. (1990), flight/fight/freeze response was linked to activation of catecholamines and the vigilance response of the locus coeruleus (Henry, 1993). This indicates a strong left hemisphere influence, which may make communication between hemispheres difficult. Henry reports that in a 1970's study by Woodman (1979) it was found that violent men react to a situation with anger as opposed to general upsettlement by more functional people. The anger leads to an increase in epinephrine and cortisol response rather than norepinephrine that is a right hemisphere reaction. Physiologically, the violent person has less access and response from the right brain. With those who would be termed normal people there would be mediation between both hemispheres of the brain enabling a more mitigating response. Part of the right brain function is that of attachment and bonding (Henry, 1993). Where these features are deficient it opens the individual to be less responsive to feelings of empathy and compassion and true healthy social interactions. In the case of both offenders and victims, it is the right hemisphere influence that has been blunted leaving an over reliance of left brain functioning. Art therapy is a model that can access right brain functioning. This includes nonverbal responses and those responses of emotional content and affect.

There are various approaches to the use of art therapy. Some will be explored briefly here from a theoretical viewpoint and will predominantly be Jungian in nature.

McMurray (McMurray, 1988) stresses the benefit of imagery and symbolism in the unconscious' endeavor to express the Self or true inner being of the individual. I should clarify that true inner being of the individual relates to where the client is "at" in the present not where he prefers to be in the future or relates to where he was in the past. She cautions that when the imagery manifests itself even in healthy individuals, one should not mistake the event as the end goal. She makes mention of the tendency for those with addiction and depression problems, to not hold on to the imagery presented once it has opened to them. She attributes this tendency to result in the client's return to their individual addictive or depressive behaviors. "The danger in images of the Self is that we may think of them as something that we achieve, a fixed goal, rather than an ever-changing dynamic process in which we constantly participate" (McMurray, 1988, p. 65). McNiff, on the other hand, encourages the use of active imagination and dialog with the images drawn (McNiff, 1992). He stressed this technique as a Jungian approach of therapeutic value. I cannot honestly say I agree with this viewpoint to the degree with which McNiff encouraged its use. McMurray's advice appears the safer approach. When the modality is used with victims of sexual abuse, I am a firm believer in the power of the psyche to heal at it's own pace. The psyche which has been exposed to past trauma appears to heal in such a way which is safe for the psychically injured client once the individual is reconciled to forward movement. It should be noted I am not overly impressed with McNiff's therapeutic theories in regard to its use with trauma survivors. My impression was that he could be a bull in a china shop when dealing with trauma clientele.

There is no doubt that the use of imagery is a valuable therapeutic tool when it is approached with respect for the individual's unique process. When imagery is dismissed for whatever reason, whether indifference or the inability to honor the image, McMurray believes it has lost its benefit as a therapeutic tool. "The image emerges from the unconscious, presenting an opportunity for contact with the sacred - an attempt of the psyche to heal itself. But if we're unwilling to know our inner nature, we limit our chance for healing" (McMurray, p. 66). I believe the importance of imagery, whether it is as active imagination, during the dream process, or therapeutic art, is that it has far greater implications for the client than what McMurray seemed to imply. I believe that the implications fall somewhere between the theories of McMurray and McNiff. I certainly agree that symbolic imagery has a significant place in the healing process. The missed opportunity, by lack of attendance to these symbols, is more the indication of the place already reached by the Self manifest in the imagery. McNiff, on the other hand, observes that where there is a particular strength of energy ("bioenergetics") in a client's drawing, the client has already internally actualized the "place where he/she wants to be" (McNiff, p.55). I have already voiced my disagreement with his projected placement. I do agree, it is a clear sign of what has already arrived and what has, in fact, been internalized by the individual. This is a very important tool the assessment of what has been internalized by the sex offender. The sex offender has mastered the elements of speech when it comes to minimization and denial. Using a model that does not readily rely on these defense mechanisms is most beneficial. This is important to the addictive and depressed client also, (offenders often present under these two categories) who often are steeped in low self-esteem. The symbolism is an explanation of where they are and not always necessarily where they are going. The symbolism would not come out of the subconscious if it were not there and already a part of the client. Were it not so, it would be unconscious and not yet internalized (Jung, 1952). Reality is, in effect, only the act or action taken because of the subconscious symbolism. It has been my experience that I consistently and ultimately act, and consciously decide, based on the conformity to my inner images. In the long term it is impossible to do otherwise. I believe this also to be the case with trauma survivors. For the trauma survivor, imagery is no longer a journey to be walked, it is a time to take note, to rest and revel in the accomplishment of how far they have come. In the case of the offender, the material elicited can be used as a means to gently confront the offender on those elements that indicate denial and minimization.

There is a benefit to perform an act that makes awareness concrete and a form of artwork is a powerful means to this end. It is equally important to let the client know that in essence they have already arrived to the point that is presented. I feel it is important to step back for a moment and expound on the use of bioenergetics mentioned by Dalley. She considers it to be a "cathartic therapy" originating with Alexander Lowen. The use of this technique is to allow the client access to an emotion where it can be openly addressed (Dalley, p. 44). Care needs to be taken with trauma victims so that flooding does not occur. Care needs to be taken with the offender also. Many offenders manifest with compulsive personalities, repetition may act as a negative reinforcer during certain exercises. The offender needs a cognitive awareness and this can be provided through art therapy without repetition. In this sense a picture is worth a thousand words.

An example of how effective art therapy can be with children who have been sexually, physically and/or emotionally abused can best be seen, in my opinion, by Jungian therapist John Allan. He has been counseling children using art therapy both privately and through the school systems of British Columbia and has demonstrated a practical and sympathetic approach. I had the good fortune of meeting him personally while at a one-day seminar at the Jung Institute in New York City where he was the featured presenter. His compassion and concern for his young clients was evident. He has written several books of which Inscapes to a Child's World is but one. He does not discount phallic symbols that often present themselves within the child's drawings but also does not give undue weight to it as would be the case with therapists of a Freudian predisposition. He looks at these symbols in the context of the whole, where weight is given, it is generally called for in that the child is depicting a symbol of actual trauma. Many of his uncovered cases of child sexual abuse have been validated, probably because of his practical non-directive approach to art therapy. He neither appears to find sexual abuse under every tree nor does he shrink from it when it appropriately appears.

Using serial drawings Allan has been able to chronicle the child's journey toward wellness. He has worked with children who have been emotionally, physically and/or sexually abused. Although he prefers the use of non-directive drawing themes he stresses that some children require a direct or semi direct approach (Allan, 1988). After initial introductions and explanations of the process, children who are referred to him, generally through teachers or guidance counselors, are requested to draw a picture with the use of pencil and paper. Allan discourages the use of crayon as sessions are 20 minutes in duration and children often spend an inordinate concentration on color use if given the chance. Allan is interested in the content and in the items that have been a particular focus of the drawing for the child. He rarely directs questions to the child during the active drawing process of the session but asks the child to expand on the symbols which were used, particularly those which were the primary focus of the drawing, once the session draws to a close. The symbol becomes the focus of the discussion between the child and therapist and in this way the child is less threatened to divulge information about which may be initially to disturbing to discuss. With children who require a directive approach he often uses the drawing technique of the House, Tree, Person projective series (Allan, 1988). Although this is a jumping off point he eventually, in later sessions, has the child client redraw those aspects of his initial drawing which appear to have a direct emotional connection to the child's underlying problem.

Within his research and clinical observation Allan has found his client's pictures to contain symbols which reflect the intensity of the actual trauma which the child is actually trying to resolve. Sexually abused children often depict graphic drawings of scenes both where and how the abuse was acted out upon them (Allan, 1988). While the child continues to draw from session to session, he/she is actively resolving the conflicts contained in the psyche as a result of the original trauma. As the problems are worked through, the child simultaneously begins to relate to his/her self and the outer world with an increased healthy outlook and personal worldview. They will often than link to the creative aspects of their selves and it's potential. The child learns to use art as a means of self-expression and healing. Not only do they create the work but are required to also perceive it and it's meaning. Once perceived the meaning can be readily internalized (Allan, 1988).

In another approach to art therapy the mandala is used as the focal point of drawing. This strategy appears to work well with mid life adults or those who are seeking a culmination of life's experience toward a sense of wholeness. This is not to say the use of mandalas is not beneficial to clients who are at odds with their psyche for pathological reasons. It can be used as an example of a therapeutic passageway to individuation and balance. This is important to the victims of sexual abuse. It would also be an interesting study if used with the sex offender during various stages of treatment.

Fincher (Fincher, 1991) has developed a comprehensive method of the Jungian use of mandala drawing for therapeutic movement. For clients who persue this medium, the act of drawing itself indicates an active commitment to therapy. This medium is also a subjective experience and within this framework it is hard to deceive. It is a powerful tool in the individuation process of which the unconscious plays such a vital part. Creating Mandalas is a wonderful little book. Ample research was directed toward the use of color, symbols and numerology in the clarification of mandala drawings. I believe it should be noted, however, that the use of color, symbols and numerology is also subjective based on the client's experiences. Fincher, however, takes the archetypal approach to these interpretations. It has been my experience when using mandala drawings and symbolism on a personal basis that they can present an interesting avenue to emotional content. Again, it would be interesting to see a progression of artwork by recovering offenders or offenders seeking to become more open to the empathetic emotions.

Zaidi presented a paper at the 8th annual meeting of the International Society for Traumatic Stress Studies in Los Angeles, CA during 1991. Research contained in that paper was a result of a time limited pilot group made up of adult male abuse survivors within an inpatient treatment setting. The researchers/therapists developed their model for the group based on the various clinical presentation of the group and current theories of therapeutic interventions thus formulating their own intervention model. Their model combined various degrees of psycho-educational, cognitive, behavioral and art therapy techniques. The group was made up of a "relatively high-functioning, chronically ill inpatients, such as those with chronic PTSD. Eliminated from the group were patients with psychosis, violent behavior, suicidality and acute psychiatric illness" (Zaidi, p. 720). The group met twice a week for ninety minutes that spanned a five-week period. Between sessions, members maintained a journal of their issues related writings and art works.

Members of the group were experiencing four areas of long term effects from their childhood sexual abuse. Specifically, they were reported to have poor self-concept including feelings of shame, guilt and having a general self view as bad or damaged. They shared a sense of powerlessness when faced with persons viewed as authority figures, a lack of trust stemming from pain and humiliation while under the care of childhood care-givers, and difficulties with sexual functioning, intimacy and relationships.

The sessions were broken into five segments covering various aspects of childhood abuse issues.

Session 1 focused on developing an understanding of child abuse. This was considered to be a psycho-educational component. Areas covered the descriptions of types of abuse and statistics as to prevalence rates. This component was useful in decreasing the client's propensity for self blame. An adjunct activity during this phase was the use of art therapy to show low self-esteem such as the individual victim's perception of body image, view of the opposite sex and affect related material. Victims were asked to interpret their own artwork.

During Session 2 the patients were asked to explore and share the dynamics of their family of origin. Since this area of exploration tended to generate anxiety, the session also included lessons in the use of deep breathing, muscle relaxation and guided imagery. These particular techniques were stressed as coping tools for future stressful situations.

Sessions 3 through 5 addressed the traumatic memories of the victim's childhood abuses. It was felt that by sharing these memories, individuals within the group would feel less singled out as victims. This phase was an effort to overcome the stigma of secrecy inherent to the acts of the abuse and reduce anxiety levels that occur with disclosure of the abuse. Each drew a time line of their childhood experiences to illustrate periods of abuse in their history. During the five sessions the therapeutic intervention included identifying both the adaptive and maladaptive behavior patterns used in childhood and later into adulthood.

Session 6 involved writing exercises in which the individuals wrote letters to the abused child within. This was used to reinforce and "heighten awareness that the child victim is not culpable (David, 1990)" (Zaidi, p.723). Upon completion of the self-nurturing exercise the following session addressed anger issues by writing a letter to the abuser which was shared with the group. This phase of therapy initiated further skills, as follows:

1.Learning to attend to the 'inner voice' that directs responses to various situations;

2.Developing awareness of messages internalized from childhood and how such messages effected self-concept as well as perceptions of how one is viewed by others;

3. Attending to thoughts and attitudes about sex (Zaidi, p. 723).

During Session 8, art therapy was again used as an intervention tool. Patients were instructed to make a collage depicting male-female relationships. This included dividing a paper in two and listing on each side words relating to what it means to be a man and what it means to be a woman. Discussions were then initiated covering areas of sexuality, relationships and intimacy. The author stated, "Interestingly, members of the pilot Child Abuse Group, with one exception, depicted females as happy, attractive and carefree, whereas males were represented as solemn, angry and burdened by the troubles of the world" (Zaidi, p. 723).

Session 9 was again psycho-educational in that it covered the use of various parenting styles, including the difference between discipline and punishment. Techniques for positive parental discipline were also explored.

The final session was an overview of the group process and discussion for future counseling sessions and referrals to outside agencies after discharge

As a result of the pilot model researchers felt that the response from patients was positive. In regard to the use of art therapy, individuals who were initially reluctant to partake in the art activities later stated it was a particular powerful and helpful tool within their therapy.

Another therapist, Dalley, had valuable and interesting insights to the use of art therapy in the prison system. She had worked with this system and gave a practical view of its use in prison life. Although the environment is restrictive, the value is evident. She states that a therapist should expect to encounter several pitfalls if this avenue is pursued. One pitfall can be with the administration. Where art therapy has been approved for use staff should be included within group work. Many staff members and administration see the use of art in prison as art education, as do many prisoners initially. The cathartic nature of art therapy is viewed with suspicion. The cathartic nature, however, is strong. It's use should be of a decelerated rate when uncovering emotional content (Dalley, 1992). It does no good to the staff or individual client if, after sessions, the client is left to his/her own defenses to sort out strong emotions associated with uncovered psychic material. In cases where prisoners have acted out, the administration often curtail the individuals involvement in art sessions. The administration generally considers art to be a class education and will curtail the privilege as a response to an acting-out inmate. Dalley found that staff participation facilitated helping the administration to see "that the use of art may well alleviate, rather than aggravate tension" (Dalley, p. 149). She discovered, over time, that when art was used as an initial assessment tool for newly incarcerated individuals, the prisoners more readily included themselves in later art groups. She also found this initial knowledge of the prisoner beneficial to the therapeutic process in her later groups.

Dalley was able to use her skill and reputation to encourage the use of art shortly after the establishment of a special unit within the Scottish prison system for prisoners serving life sentences. After 10 years it was discovered that these individuals, who had been deemed extremely violent and with little sense of hope of the future, had formed a peaceful, working community. Dalley stated, "Now, ten years later, most inmates who have been in the Unit involve themselves in some art or craft form. Furthermore, the concept of creativity permeated through daily living...Art is not a privilege or a luxury; it is an essential part of life. Art in prisons, by releasing tension, aggression, hatred and violence into a meaningful form of expression offers a basis for building relationships" (Dalley, p. 151). I find this quite a testimony to the value of creativity as a motivational process and balanced sense of self.

Gerber (Gerber, 1994) has used art as a model of treatment for juvenile sex offenders. He is an art therapist at the Children's Center for Behavioral Development, Centerville, Illinois. In an article written by this author (Gerber, 1994), he gives an overview of the characteristics and pattern cycle of the adolescent sex offender research since 1986. It focused on an intervention model for young offenders who often began offending as early as 8 through 16. It is believed that by beginning treatment in the form of cognitive - behavioral models, the offending cycle can be interrupted before it has become a well-ingrained pattern of behavior. Treatment includes helping the offender to understand his/her offense cycle that includes "the circular chain of events, thoughts, fantasies and feelings which lead to the offense" (Gerber, p. 367). Although juvenile sex offenders differ in their patterns, the author states there are common traits to all these offenders, as follows:

1. Lack of accountability. Common cognitive error in thinking patterns allow for denial, blame of others or minimization of their own responsibility for their behavior.

2. Inability to identify common feelings states.

3. Lack of empathy for others.

4. Lack of understanding and respect for boundaries of others.

5. If you have a healthy relationship with peers and/or adults

6. Common thread of abandonment, lost and betrayal issues from early childhood.

7. Low self esteem.

8. Offence is seldom for strictly sexual reasons. Common themes are power and control, conquering the trauma of his or her own victimization, anger, revenge, and inadequacy" (Gerber, p. 268).

The author has used art therapy to assist the offender in the identity of the situational, psychological and behavioral elements involved in the individual's cycle.

In many forms of therapy, the therapist is supportive or neutral to the verbalizations of the client. I stress again, however, that sex offenders use denial or minimization, which make them resistant to these normal forms of therapeutic intervention. During art therapy it is difficult for the offender to use these normal defense mechanisms because the offender uses a concrete visual image which makes denial difficult. "What appears to be central to the effectiveness of the art process in this treatment is the creation of an object (art product) in which the clients internal processes can be externalize to and given concrete form" (Gerber, p. 368). (In my opinion, this would not be specific to only the use of art in therapy but also in other creative therapies where symbolism is used, such as drama or the use of poetry.) Art therapy with the sex offender requires that the therapist be confrontational, but as in other therapies, must maintain a respectful demeanor.

The other issue common to sex offenders and victims of trauma alike is that of the lack of emotional affect, which is also particularly conducive to art therapy intervention. During normal effective talk therapies the individual generally relates verbally causing an emotional or abreactive emotional response. During art therapy the emotional content to use placed at a safe distance. "It allows clients to illustrate and his inner experienced and give it concrete form. The volatile, threatening experiences may then be viewed from a safe distance" (Gerber, p.369). This process would minimize the need for the offender to utilize his normal defense mechanisms and diminish negative flooding of strong emotions. In the case of art therapy with victims of sexual abuse it is a valuable tool as the therapist explores emotional content in a supportive way. With offenders the therapist can explore in a confrontational way the abuse cycle of the client. "The art object remains outside and provides a vehicle for reintegration. This tolerance can than generalize into the clients overall functioning and diminish the need to reduce tension through invasive sexual activity" (Gerber, p.369). The client is first allowed to address the art form in a detached way and later in more specific components.

Gerber states in his 1994 article that the use of art therapy with sex offenders has three major goals for therapeutic intervention. First is accountability of the offender to the offense; the second use is to reopen the door for the offender's emotional affect that has been dormant. The third goal is a result of the second goal, to assist the offender in "understanding and exhibit of empathy for the victim of his or her offense" (Gerber, p. 370).

The author who initiated the tools using group sex offender situations described specific art therapy interventions. Gerber asked group offenders to make masks of themselves as perpetrator and another as victim, both displaying the feeling states. Upon completion, the group had to formulate a conversation between the victim and perpetrator mask where they played both victim and offender. This treatment intervention was used to create an empathy collage where each member had to select a picture depicting another individual in the group. Once the collage was created, the group discussed such questions as why the image was created and how they reacted to the image selected by others. The author stated, "juvenile sex offenders are often self absorbed and narcissistic. Tasks such as this are valuable in helping the individual to see outside of themselves, understand another person's perspective and to develop social interaction skills" (Gerber, p. 370). Other uses of art therapy are to have the offender draw pictures, which show their boundaries, and those of others. In many cases the therapist can then address the power and control issues of the offender in such ways as displaying within the picture the differences of age, the size or knowledge discrepancies. Particularly useful, were exercises where the offender was required to draw a sequence of pictures depicting their own high-risk situations. These were situations, which showed their own patterns leading up to, acting out the offense and the later consequences. It was requested that these pictures display as much sensory detail as possible. By also showing the consequence, example - being arrested, the fantasy aspect of the offender's pattern is brought back into reality. It was emphasized that the offender's pattern of maladaptive behavior is deeply ingrained and supported psychologically, physiologically, and emotionally. In order for art therapy treatment to be useful, the offender requires constant repetition in order to internalize the more adaptive behavior patterns. These particular exercises would be invaluable for use with the special needs sex offenders who have a low functioning level and often do not have established writing or reading skills. To date the direct benefit of the use of art therapy with sex offenders has not been studied to determine what, if any, rate this particular therapy model has in relationship to recidivism rates.

It is also important to note that care must be taken when using art therapy just as a clinician takes care in any other treatment model. It is a powerful tool and actively links into the client's emotions. Frye (Frye, 1993), a senior occupational therapist at the Akron General Medical Center in Ohio, and Linda Gannon, a social worker in Akron Ohio, caution therapists using art therapy with DID/MPD clients.

Frye and Gannon are concerned that therapists, who have little or no knowledge of art therapy, are being presented with drawings from their dissociative patients, who often use art as a form of expression without prompting from their therapists. Their article is targeted for the therapist without training in the art therapies. It outlines practical guidelines for its use and misuse. Patients who present with dissociative symptomology are often creative and prone to suggestion but have difficulty using verbal language to discuss the past abusive situations. In the beginning stages of therapy many dissociative patients, who use art as a means of expression, are also amnestic to the past occurrence of the abuse. Dissociation is an effective defense mechanism used by the patient to avoid memories that may be too painful, or overwhelmingly anxious to deal with. It is essential to respect the process so as not to overwhelm the patient thus furthering a regressive state.

It is felt that the use of art is one way to side step the initial stress caused by telling the secret. Many victims were repeatedly told not to speak of the abuse; many of these victims were threatened. Persons with a dissociative disorders often lose track of time. The use of art between sessions is helpful to keep the patient in touch with their sessions during periods between therapy appointments. It can be used as a method of relaxation, perhaps drawing peaceful scenes, to help the client from escalating stress. The art medium also can give the patient a sense of the power and control that had been lacking in their childhood. It is a safe tool for the client to express freedom of choice; they can create drawings "large or small, messy or neat, shared or not" (Frye, p. 189).

Anger is a major symptom of those who have been abused. This manifests itself in overt and covert ways. It can range from deep depression, self-mutilation, to outward acts of violence toward others. "Art provides an option for releasing rage that reduces the likelihood of further traumatization by the use of restraints, heavy medications, and frightening physical contact (in hospital or correctional settings)" (Frye, p.189).

During various stages of therapy the art products of the patient may display an awareness of past memories of the abuse whether the individual is willing or able at the time of the drawing to verbally express the event. It can also be used to represent present or past conflicts or depicts the future goals of the patient. As a powerful tool it alters the victim's pattern of denial. "Under the subtle influence of the intuitive and spontaneous right brain (Edwards, 1979), a patient's art doggedly chips away at the defensive walls of the left brain which logically tries to account for the past" (Frye, p.189). Since patients who suffer from dissociative disorders usually suffered intense forms of abuse and pain, the use of the left brain to formulate logical accounts of the past is often futile; the past defies logic.

The child that had been extensively abused lived in environments where truth was distorted. The abusive family often displays their best behaviors to the outward world. Abuse is denied or explained away as resulting from the child's behavior. It is like a picture album where everyone dresses up at the holidays and family events, smiling for the camera. The use of drawing in art therapy presents a picture album that is more in keeping with the true experience of the individual. "As painful as their realities may have been, and despite the vicissitudes of memory, patients need the integrating sense of wholeness and continuity that is their unique life's story" (Frye, p.189). For the dissociative patients who are diagnosed with dissociative identity disorder (formally called multiple personality disorder), this becomes a shared history involving a continuum with which the parts can relate to the whole. "The concept of unity is reinforced (Torem & Frye, 1991)" (Frye, p.189).

Frye and Gannon warn of possible abuses by the therapist when using art therapy as a treatment tool. The therapist must continually remind him/her selves that the therapeutic interaction is the predominant focus. It is not beneficial to the client to accept works of art, either as gifts or in outright payment, as these clients often have a need to please. It is more beneficial to discuss this need in a loving way so as not to give the client mixed message. In cases where the client is diagnosed with dissociative identity disorder, overemphasis on art works by one or more personalities at the expense of the total personality can be detrimental to the patient in the long term. The end goal is not to strengthen only parts of a personality but to seek unity.

It is also important for the therapist not to have the client overly dwell on traumatic memories when using art as therapy. It is also essential for the client not to be overwhelmed by this material. As mentioned above, the client at the beginning stages often cannot verbalize the abuse; a balance must be maintained to strengthen the individual's internal coping mechanisms. In this same vein, the client who is dealing on several levels of awareness, may repeatedly seek interpretations of their art material. While the therapist may be aware from the presentation of the drawings what the underlying problems are, the individual needs to come to their own conclusions in their own time. As Frye states:

Analyzing or interpreting art work directly to a patient can be harmful because

1) the analysis/interpretation may not be true,

2) the patient may not be ready, and

3) if it is not true, the patient may believe it because he or she is highly suggestible.

Patients sense when they are ready to move to a new level of awareness and find their own meanings when given room to do so (Frye, p 191).

Again, it needs to be emphasized that unlike art therapies used with victims of sexual abuse, work with offenders is of a more confrontational nature to break through their denial and minimization.

In conclusion, the use of art in therapy can be a powerful tool that offers particular insight into the psyche of the client. Its use needs to be tempered according to the client base. Regardless of it's use with the victim population or the offender population the therapist needs to be mindful that flooding of uncovered material is never beneficial to the client. Responses to the use of art in therapy can have a neurophysiological effect caused by the flight, fright, freeze reaction of the autonomic sympathetic system on the client as they balance their need to disclose that which is causing them an imbalance of their psyche and/or circumvent their denial or minimization processes. Symbolism is a global language that may be archetypal in nature but is also subjective to the individual within the context of that culture. As in other therapies, the therapist has to be mindful that: above all do no harm.

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