Rivkah (Rebecca) Hetherington MA fine arts; HCPC registered art therapist and psychologist

“Initially I thought the art therapy sessions were useless. I really didn't want to go. Then after a year I began making great strides. I started to open up more to others, to be more emotional, to express my ideas. I began to see my life in colour, instead of just grey. I am more controlled now.” (Federico Gentile)

This paper is based on an interview with 13-year-old Federico Gentile (pseudonym). He has had weekly individual art therapy sessions for two years. Art therapy began fifteen months after he began living with his adoptive parents.

Trauma can be defined as the rupture of a boundary on many different levels (physio-logical, psychological, social). A common thread throughout the sessions was the testing and re-pairing of boundaries. The therapist herself found it necessary to break two boundaries: giving the user a gift and integrating Somatic Experiencing (SE) techniques from outside our field.

SE has enhanced my ability to work physiologically, integrating bodily sensations with affect and imagery. Further research could offer guidelines towards an integrative approach that could be useful to other psychodynamically trained art therapists working with attachment trauma.

Trauma has physical as well as psychological consequences and therefore needs healing in both these aspects. A form of art therapy known as ‘sensorimotor’ that focuses on bodily sensations and muscular (motor) responses has been developed for this purpose (pioneered by Cornelia Elbrecht), based on knowledge gained from Somatic Experiencing (pioneered by Peter Levine). I am trained in Sensorimotor Art Therapy and have found that further training in Somatic Experiencing is helping me introduce this outlook into my art therapy practice, allowing me to shift my focus when necessary from the art materials to the body: the body’s response as it interacts with the materials. I believe this could be useful to other art therapists who wish to broaden their horizons in this direction. I interviewed 13-year-old Federico Gentile (pseudonym) in order to present his experience of art therapy from his perspective. At the time of interview, Federico had done art therapy with me for 2 years. We began sessions fifteen months after he began living with his adoptive parents. I find it helpful to think of trauma as an experience that goes beyond our limits in many different ways: it challenges our physical, mental and social limits of toleration. As such it is no surprise that our therapy was centered around testing limits. As the therapist, I overstepped two limits: giving the boy a gift and integrating Somatic Experiencing techniques from outside our field. Federico talks about specific things in art therapy that helped him be “more controlled now” and see his life “in colour, instead of just grey”. There is no one answer to healing trauma and sometimes, when we are beyond our limits and don’t ‘know’ what’s right, we can only respond by ‘feeling’ what’s right. Somatic Experiencing helps us contact and trust that ‘feeling’.

Federico Gentile (pseudonym) is approximately 13 years old and lives in North Italy. His adoptive parents approached my studio privately following recommendation from the psychologist at the Child’s Mental Health Centre that art therapy could be useful. When sessions began, he had been living with his adoptive parents for fifteen months. The adoption was legally completed 18 months after sessions began. At the time of our interview, I had been seeing him weekly for one-hour sessions for just over two years. I see the parents bi-monthly for parental guidance on managing behavioral difficulties related to post-traumatic stress. I am in contact with the psychologist at the Child’s Mental Health Centre and Social Services, where the parents attend individual and group support meetings. Federico has been included as co-author to this article because he has made a direct contribution by sharing his lived experiences of art therapy. This has been done at his request using the format of a recorded interview. Federico’s part of the article (in italics) has been taken directly from this interview. Federico has approved the extracts used, chosen the illustrations and created his pseudonym (see Author’s Biography). We decided together not to include the illustration of the therapist’s gift (The Tiger), as this remains his personal and private property. Both he and his parents have received an Italian translation of the finished article. Parts of this article have been written in a more informal style than may be expected in an academic journal. This is to ensure that it remains accessible to Federico and to align it with our therapeutic work of discovering emotions as something other than shameful or dangerous.

Introduction:

Theoretical framework: Integrating Somatic Experiencing (SE) with Art Therapy to create a mixed physiological-psychodynamic pathway “If I go over the edge when I’m painting at school, even just a little bit, I’m always worried that the teacher will get angry. Here I know I can go over the edge and nothing happens. Because a person shouldn’t have limits. I wasn't talking about going into a museum and screaming, when I say that here, in this space, there are no limits.”

Federico often has to deal with the consequences of behaviour that ‘goes over the edge’ caused by states of dysregulation: hyperactivity in the brainstem and midbrain that creates impulses his cortex has limited power to control (Perry, 1997, 2009; Levine, 1997). The question, “Why did you do that?” is as unanswerable as it is humiliating. Perry (1997, 2002, 2009) and Schore (1994, 2003) have written extensively on the long-lasting physiological and neurological consequences of traumatic experiences (be they in the form of abuse or neglect) on the developing brain. The gravity of these consequences is necessarily related to the stage of development: firstly, because each stage is built upon the previous one and secondly because the extent of the effects will depend upon the resilience of the nervous system at that moment in time (Perry & Winfrey, 2021a). Both Perry and Schore have examined the interconnected neuroscientific processes (eg single-trial learning, synaptic sculpting, circuit overpruning) that determine what Perry (1997) terms ‘compromised cortical modulation’ and Schore (2003) ‘affect dysregulation’. Core to this phenomenon is an over-(re)active stress response system (lower and mid-brain) that leads in time to underdeveloped limbic and cortical areas (Perry, 1997). Perry outlines key symptoms that include behavioral impulsivity, cognitive distortions and hypervigilance connected with “a persisting state of fear” (Perry, 1997, p. 132). Within our sessions, I lived this “persisting state of fear” (Perry, 1997, p. 132) as a consistent feeling of being “over the edge” and beyond my limit, exactly as Federico describes. And this is where I have found Somatic Experiencing (Levine, 1997) an invaluable tool that has enhanced my art therapy skills. I was introduced to Levine’s work thanks to my training at the Institute for Sensorimotor Art Therapy (Elbrecht, 2020) and improvement in Federico’s physiological symptoms coincides temporally with the gentle introduction of somatic techniques into our sessions. At the simplest level, this has meant using SE on myself during sessions to track my responses and remain regulated, thus favoring a regulatory response in Federico. Elbrecht (2021, p. 25) emphasizes the usefulness of SE for this purpose. In the same way, SE has helped me pick up the subtle first signs of hyper- and hypo-arousal in Federico and guided me in my physical responses so that my deep breath as the paint drips over the table from his paintbrush is no longer a reflex that escapes me but a conscious action that promotes a similar effect in him. This technique is also valued in Sensorimotor Psychotherapy (Ogden, Minton & Pain, 2006): Fisher (2020, 2021) reports how she mirrors her client’s posture and then adjusts her body with small changes to see if they follow. Van der Kolk (2015b) shares how he learnt the significance of posture from Levine (1997), the creator of SE: it is impossible to feel energetic and full of joy while hunching one’s shoulders. The body needs to change position to grasp the emotional transition. Somatic Experiencing, Peter Levine (1997) and Federico have taught me that integrating trauma means working outside our own boundaries, including those of right and wrong. It has given me not only physiological tools but a changed mindset, a prerequisite for SE’s technique of renegotiation. I found that I could not step outside the binary of victim-aggressor as long as I remained in a position of judgement. SE’s physiological perspective helped me renegotiate judgement as a defence mechanism against fear. It was a sign that my own limits were being surpassed and I needed to settle myself to be present for my user. I have used SE to bring curiosity into the setting as an antidote to judgement and a means of re-establishing safety. Renegotiation has helped Federico and I explore memories of school events that had triggered post-traumatic behavioral responses in him. We did this in order to introduce a resource and begin to alter the impact of the memory on his nervous system’s level of activation. On a theoretical level, SE has given me an interesting framework in which to consider the creative process: ‘SIBAM’, the five levels of human experience (Sensation, Image, Behaviour, Affect and Meaning). For example, I have worked on integrating ‘Sensation’ and ‘Behaviour’ by drawing attention to Federico’s neurological responses and verbalizing changes in his physiological state while we are painting, playing or involved in an imaginary game. According to Levine, Selvam and Parker (2003), over- and under-coupling of or within these levels can cause physiological phenomena associated with trauma e.g. a specific smell that triggers a specific behaviourial response. An example in complex trauma is given by Perry & Winfrey (2021b) in the seemingly inexplicable aggression of a child in the classroom when a teacher approaches kindly offering to help. “A person shouldn’t have limits” says Federico. His experience of limits is of something punitive and … limiting. They are constrictive. SE (Levine, 1997) identifies constriction as a physiological response to fear. But the action of constriction can become itself a messenger of fear (Poyo Solanas, Vaessen & de Gelder, 2020). It is a double-bind. Conversely, as I feel safe, my muscles relax, space opens up in my body. But I also become aware of the chair under my sitting bones, of my skin under my clothes, of my lungs pressing on my ribcage as they expand … of my body’s boundaries, of my point of contact with the outside world. The relevance of this in terms of my psychological well-being can be found in the field of Sensorimotor Art Therapy in Elbrecht’s (2013, 2021) research on the significance of haptic perception and in the field of psychoanalysis in the research of Anzieu (2016) on the skin-ego, developed from Winnciott’s (1976) understanding of the body ego and Bick’s (1968 & 2002) adhesive identification. As Deuser in Elbrecht (2021, p.298) notes, we cannot touch without also being touched. Any relationship incurs contacting the limit between ‘me’ and ‘not-me’, physically, psychologically and symbolically. Attachment theory explores this as “proximity set-goals” (Ainsworth et al, 2015). And yet in terms of our haptic proprioception, Anzieu (1986, p 64) notes: “The skin is so fundamental, its functioning is taken so much for granted, that no one notices its existence until the moment it fails.” Before encountering SE, I was able to explore these limits with Federico psychodynamically through the creative process. SE has awakened my felt sense (Gendlin, 1978) and enabled me to add a somatic and physiological exploration. The practice description explores this.

Practice Description: the centrality of boundaries in working through attachment trauma Breaking the boundary: Playing football in the art therapy studio “One thing that has helped me a lot is definitely playing football here. Because it is a sport that needs space. We have enclosed it in a room of about 20 square meters. What’s more, the football itself is like the core of our journey together because we are both inside it, and protected by the outside that is like the armor, the leather of this ball. And do you see these joints, where the bits are sewn together? These are like the stained-glass window we made together and all our artworks are enclosed with us inside this ball, and that means … sooo much.” Like many pre-adolescent boys, Federico loves football. We’ve played it together in my studio since our first sessions, with the primary intent of building up our relationship and creating a space that is gratifying for him. It’s become an opening ritual that dominates the first half of many sessions. As his comment shows, it has achieved this aim but has also become much more than this. Federico’s contribution opened my mind to a key factor I hadn’t previously taken into consideration. His childhood reality was full of lived experiences that drew attention to the impossibility of meeting certain needs and the harshness of the ‘reality factor’. His words helped me realize how our games of football have provided him with a much-needed lived experience that obstacles can be overcome in his favour. In his mind, football was a game that required so many players and so much space, and certainly couldn’t be played indoors. The possibility of adapting this game and overcoming limitations in such a way that isn’t just a compromise but becomes a genuinely enthusiastic and emotionally rewarding experience, has provided him with a long-lasting lived experience that the ‘impossible’ can become ‘possible’, just as during the course of our sessions the impossibility of a stable home has become a lived possibility. The games of football test the limits of the space, offering a lived experience that this can be done safely and without irreversible damage. Preparing the space together has become an important ritual: moving furniture from where he can fall against it, cushions across the floor, non-slip socks. Of course, art materials get knocked off the shelves, accidents happen but each time, thanks to SE, we explore the nervous system’s reaction together by tracking and verbalizing bodily reactions, ascertaining that nothing dangerous has happened, re-orienting with playful curiosity and clearing up any mess, seeing if we can spot anything else that should be moved to a safer place. In this way, time after time, his nervous system lives a contained experience of a manageable threat response cycle: arrest/startle, defensive orienting response, completion, exploratory orienting response. A continuous repetition of lived experiences of alternative endings.

Contacting the boundary: painting directly on the wall and furniture “Compare this. You have to do something for school at school. Maybe on the wall. But you can't actually use the wall. You have to use a sheet of paper. So you don't feel in contact with the wall, with the matter you are using, because you are using an intermediary between them. Instead I don't use an intermediary here. I use the material directly and it’s very stable.” Federico brings the need to find a support that is strong enough: a support that is permanent. And in practical terms that translates into the walls and furniture: the structure of the studio itself. Nothing else is good enough. I have deliberately organized my studio to make that possible. Klingman, Shalev & Pearlman (2000) and Tezsta & McCarthy (2004) have demonstrated the importance of murals, street art and graffiti for individual and collective trauma. I would like to emphasize an important distinction here. Federico’s primary concern was not the permanence of the mark, but the permanence of the support. As a child who has lived through institutions, Federico didn’t need sheets of paper that could accidentally tear and rip, confirming that the world was as fragile as he thought it was. Before he could have a stable object that could be his and be kept safe, there had to be a stable world in which this object could exist. There is a hierarchy of needs. The painting as an object had not yet become relevant. Federico was interested in the sensorimotor experience of applying pressure to a surface that resists. We may read this psychodynamically as the experience of reliable support. It is also a physiological experience that needs to be registered by the nervous system and here SE was again useful in tracking the body’s physical response to the wall’s solidity. Once that experience has been internalized, once there is a stable world, there can be space to attribute value to the object and desire its permanence. One year later, he asked to paint directly on the children’s table. I said “yes”, but warned him that the painting might be damaged by others using the table. We put masking tape around a square to define an area he could paint in: a blue monograph. He seemed disappointed with the result. I said it was beautiful and he had given me ‘a piece of sky’. “This painting on the table that you called ‘the sky’. Well, at first, I just did it slap-dash without putting any effort into it. Because I thought it wouldn’t last. But you, you gave it a lot of importance. You kept giving it attention and now it’s come alive, it has a soul. And then, when I saw it had got chipped a bit, I said: I have to do it again. Because I really liked the idea and it had become important.” We learn from others and Federico’s feedback shows the importance of the way in which I validated the art-object, confirming his right to desire its permanence. The process began with investment in the support: he needed to paint on the table and neither the painting’s subject matter nor its longevity was important. This then develops into an emotional investment in the object where by the painting gains value, receives a name ‘the sky’ and earns reparation and maintenance over time. The process opens the way for what I refer to as ‘the right to exist’. In his own words: “When I enter the studio I always see the wall that’s all coloured and covered in paint and this is the most beautiful thing of all.”  It certainly is the most beautiful thing. He sees himself. He sees what every child needs to see. The world that looks back and sees them. It’s the painting pinned up on the fridge door. It’s sports day, knowing your parents are in the crowd cheering you on. It’s breakfast, lunch and dinner on the table every day. It’s all those things that have been done for you, and that in time you internalize until you know how to do them for yourself. And now, he showed me that he had indeed ‘grown up’ and could do them ‘for himself’: “When I painted the goalpost and repainted ‘the sky’ I didn’t want you to see me doing them because I wanted it to be a surprise.” These were two key pieces in which I had acted as an auxiliary adult showing him how to do them, containing his frustrations and guiding him through the process. Now that auxiliary adult had been internalized and he was able to take care of them on his own. He asked me to leave the room and I sat in the bathroom, waiting as the cardboard goalpost, that for one year had remained its varied shades of brown, turned his favourite shade of blue. He really did begin ‘to see his life in colour’.

Strengthening the boundary: Expressing anger by smashing up wood “It was a moment of anger. When a person is angry with another person, he must not vent his anger against them in person. As my mother says, when you are angry you shouldn't touch people, animals or things. But if you have something that you can break, and you have a tool with which to break it, and you are with another specialized person who says "Yes. You can do it.” Well, I don’t think you’d hesitate a moment, would you? And after you’ve broken a wooden board… well, you just feel so calm. Tired out. Like you’ve given away all of your anger. But I also felt really satisfied that I had broken a wooden board.” The session that Federico describes created an important lived experience that anger, even in its physical expression, could be controlled. It took place after two years of work increasing sensations of safety, nurturing resources and bodily awareness. Anger was a feared and dangerous emotion for Federico because of the uncontrollable nature of his lived experiences of it, primarily from others, and secondarily through his own post-traumatic outbursts. He asked me to roleplay his assistant, officiating my responsibility to provide security and limits. I was to manage safety equipment and procedures (fitting eye goggles, placing protective cushions, measuring safety distances, saying when to go and when to stop, providing sustenance in the form of water). My training in SE enabled me to slow down the procedure and draw attention to somatic markers (breathing, sweating, muscular tension). In this way, what had previously been lived as an experience/emotion that controlled him, now became an experience/emotion he controlled.

Pierre Janet’s research (1903) on vehement emotions that arise out of insufficiency of action is useful in providing a theoretical framework (van der Hart & Rydberg, 2019). Vehement emotions are defined as such precisely because of their intensity and violence: by definition they are dysregulated and have a disintegrating effect on the personality (Janet, 1903; van der Hart & Rydberg, 2019; Ogden, 2020). Janet (1903) attributes their origin directly to the insufficiency of action and his treatment methodology recognizes this. He worked with his patients to develop adaptive actions that had the power to transform vehement emotions into empowering (sthenic) emotions, witnessing how this promoted adaptive integration (Janet, 1903; van der Hart and Rydberg, 2019). This concept of fulfilling thwarted motor responses is at the heart of SE’s practice of renegotiation (Levine, 1997) and of specific trauma-informed techniques in sensorimotor art therapy (Elbrecht, 2013 p.186 & 2018, p.229). Janet (1903), van der Hart & Rydberg (2019) and Ogden (2020) emphasize that the vehement emotion must not be expressed in its vehement form, as this would only re-enforce its dysregulation and lead to re-enactment. Similarly, SE practices titration and pendulation to avoid hyper and/or hypo-arousal. Actions must be adjusted so as not to create agitation or emotion that goes beyond what Siegel (1999) terms ‘the window of tolerance’. Regulation is the key word to describe the session in question. The energy could be equated to that of a science experiment: the study of a mathematical formula between the power of the body’s muscles, the strength of the hammer and the surface of the wood, to calculate the moment in which the wood would break. It was very different from the cathartic expression of anger as a disconfirmed, attachment-related core emotion (Ogden, 2020). In my experience, the latter tends to give way to a sense of relief and a space is created for under-coupled emotions and beliefs to emerge: an angry person will suddenly find themselves crying and contacting the sadness the anger protected themselves from; a sad person will vice-versa discover their anger. The process is externalizing. Instead, Federico’s expression was characterized by an internalizing force, an integration of the emotion that led to its containment and gradual reduction. He describes himself feeling ‘calm’ and ‘satisfied’. Janet (1905, p.108) describes how empowering emotions “induce calmness, strengthen the visceral functions, arrest the useless mental agitation and replace it by an increased activity of attention and will.” Federico was present in the here and now and his account demonstrates a lucid memory of the event. In terms of SE’s theoretical framework, a step was taken in uncoupling an affect (anger) from an automized behavioral response (striking out). He discovered he could be angry without losing control, powerful without being angry. He could be strong and safely strong. When we sat down together afterwards he immediately asked to see some artworks that represented a safe attachment bond. The symbolic message I perceive is: if I am to love another and have another love me, I need to feel safe in that relationship. I must trust the other not to hurt me, and I must also trust myself not to hurt the other.

Crossing the boundary : Receiving a present from the art therapist “The most important moment for me was last Christmas when you gave me the painting of the tiger cub. Because you made the impossible become possible. I had said, “It’s beautiful. I would like to buy it. Who knows if I'll ever actually be able to have it?” Then Christmas comes and I see a red package. And I open this red package at home and find out it was that painting. And I didn't hesitate a second, and I told my parents to go and hang it in my room because it was very meaningful to me because this painting had been in the studio ever since I arrived. And now this year, I have it. You gave it to me. “I know it was the most significant moment because that tiger represents for me our whole path-way together that is not finished yet. But that tiger was there when we started and it’s seen every-thing we did together. Because when we made the goalposts, it was there. And it saw that. And it saw it too when we re-did them again. And whenever you taught me to do something, and you taught me to be more expansive… the tiger was there. And now it’s with me and I never have to say goodbye to it.” Federico’s words offer an important insight: the tiger had been lived as a witness. Art therapy theory has placed emphasis on the triangular relationship between therapist, user and artwork, the latter becoming a ‘third object’ that can hold the transference and take on many of the therapist’s roles (Wood, 1984; Luzzato, 1989 & 2009; Della Cagnoletta, 1998). The painting in question is an artwork from my parallel career as artist that I had hung in the studio. Its consistent presence within our sessions transforms it into a third object, that does indeed hold Federico’s transference. The tiger becomes an active presence and Federico clearly describes how it takes over the therapist’s role as witness. Indeed, my possibility of acting as witness myself was compromised by the heavy level of interaction during sessions. I was rarely ‘external’: almost always active participant. In the tiger, Federico found his own spontaneous solution to this problem. This highlights how much our users have to teach us, as well as how potentially significant any object may become once it is placed inside our setting. The painting had attracted his attention and admiration right from the first session and he had consistently made references throughout our meetings to his desire for it and the impossibility of this ever becoming true. His desire had opened up a parallel desire in me to grant this wish but I recognized that the gesture had no place as simple gratification. There is an important distinction between two forms of giving: satisfying my need, or his? And the subtle distinction between this radically changes the energy of the exchange. Giving a gift can potentially create guilt, dependency, confusion of roles, and hence difficulty in separating (Gutheil & Brodsky, 2011). Before making the decision, I took time to connect with my ‘felt sense’, the basis of SE (Gendlin, 1978). When I imagined the tiger with him, I noticed myself feeling stronger, my back becoming straighter and more upright, my breathing more even. I saw Federico in his room with the painting and able to shut the door on me. This gift functioned to promote autonomy as Federico’s statement confirms. In the period prior to the gift, I had become aware that Federico’s investment in the space was potentially difficult for him to manage. First of all, a comment made by Benjamin (2020) regarding her work with adopted children raised important questions for me. She proposes an approach that avoids a long-term dual therapeutic relationship with adopted children, arguing that it is a relationship that is destined to end, and that these children have already suffered enough abandonments. Not long before this, an incident had taken place in our sessions that communicated the intolerable nature of an ending. Federico had picked up a clay jug that we had made together that represented his uniqueness as a service user: everyone else drank water from the filter-jug, he had his own clay water-jug that only he could use. He held it in his hands and informed me that when our sessions ended he would smash it. Something would be irreparable. Federico’s investment in the tiger as the witness of our sessions explains how receiving it as a gift repaired this. Thanks to the tiger’s tangible movement from my space to his, becoming a transitional object (Winnicott, 1974) bridging the gap between presence and absence, his witness is now owned by him and is being gradually internalized. There is no longer a threat that I can take that away. It is his, to keep all of his life, if he so chooses. And we used SE to explore how that feels inside the body, where that warm feeling is, when it goes away, and when and how you can conjure it back again.

Celebrating the boundary: the art therapist receives a present. “But I want to add something about my painting that you put up in the tiger’s place. I didn't think that painting of mine was very important to you. But it became like an exchange: you gave me the tiger, and I gave you my painting. “And by doing so, you really gave me a sense of satisfaction. Because I know I'm not good at drawing but for once, thanks to you, someone gave importance to something I did. And you helped me understand this message: ‘You can draw. Your style is lovable. It has value. It's unique.’ I will certainly never be Kandinsky, or another painter like Van Gogh or Picasso. But it's me. That’s it!” A few months after giving him the tiger, Federico made a painting that was special. I asked him if I could hang it in the place where the tiger had been. As he explains above, he hasn’t had many lived experiences that have confirmed the fact that he is unique and irreplaceable. This was a special moment, when he asked me, “Why do you like this painting so much?” And I replied, “Why do you think I do?” with a particular smile on my face. And he lowered his eyes a bit as he said it, and the words were almost a whisper but he did say it: “It’s because I did it, isn’t it?” And that was a very special moment for me too. When I knew that I had passed onto him the possibility of unconditionally being valued as you are, for who you are, simply because you are.

Implications for research : Somatic Experiencing and Art Therapy I was surprised that searching for ‘Somatic Experiencing’ in both the American and International Journals of Art Therapy brought no results. I’m surprised because Levine’s work forms a central pillar of Sensorimotor Art Therapy (Elbrecht, 2013, 2018, 2020, 2021) and of trauma-informed practice in general (van Der Kolk, 2015a). SE is becoming an essential added ingredient to my day-to-day practice that has increased my lived understanding of the Sensory/Kinesthetic level of the Expressive Therapies Continuum (Hinz, 2009; Lusebrink, Mārtinsone, & Dzilna-Šilova, 2013) providing a bridge between my psychodynamic and sensorimotor art therapy approaches. It is proving invaluable both within and without a trauma context because while SE provides a specific trauma protocol (renegotiation), its foundations lie in enhancing the nervous system’s ability to self-regulate and hence the individual’s ability to regulate emotions. This makes it universally valuable. As art therapists we know how powerful art materials can be: their potential to dysregulate is equal to their potential to generate sensations. I believe that SE offers additional tools to help keep our service users safe. It has helped me identify initial physiological signs of hyper- and hypo-arousal so that I can intervene preemptively while enabling me to regulate myself more efficiently, an important first step to facilitate my user’s regulation (Elbrecht, 2021; Perry & Winfrey, 2021b).

SE is certainly not the only solution for integrating physiological solutions into art therapy (Malchiodi, 2008) but I have found it well suited for visual arts therapy: its core framework of embodied lived experience links Sensation, Image, Behaviour, Affect and Meaning (SIBAM). It has enabled verbal feedback and discussions of artworks to connect the 5 aspects mentioned above in a fluid manner. SE has enabled me to respond physiologically as well as psychodynamically to material as it emerges spontaneously within the setting. This merits further research and could be a valuable addition to compliment specific sensorimotor techniques (Elbrecht, 2013 & 2018) and short-term trauma protocols (Egger & Merz, 2013; Gantt, 2016; Talwar, 2007; Tripp, 2007).

Conclusion : treating trauma requires an integrated multi-level approach “This space is important as somewhere you can talk to a specialized person, someone with experience. Talking to a grown-up you know, for us kids, is really important. And rare. Because not everyone talks to grown-ups. And this is bad, because if little kids don’t have the chance to open up with grown-ups, I don’t think they’re ever going to get out of their problems.”  Federico describes the process in terms of ‘talking’. I propose ‘communicating’ as I feel that a significant part of our exchange was neither verbal nor cognitive. We were bodies negotiating a space, or rather spaces, as he often divided up the studio into ‘mine’ and ‘his’. There was a continual rhythm and flow between action and pause, excitement and relaxation, sympathetic and parasympathetic nervous states, anger and kindness: bodily sensations that indicate the emotions emerging, and motor responses that can be harnessed as a tool to regulate them. Thanks to SE I was able to track my physiological state in parallel to my understanding of the space in terms of the art therapy’s psychodynamics, working at two different levels as Ogden (2020) describes. This article highlights the complexity of treating trauma with children and the necessity of a multi-leveled approach. As the practice description shows there was no one factor or methodology that ‘cured’. In my professional experience, children rarely use art materials to produce finished art objects and their use of the therapeutic space is distinctly different from that of adults. As Federico says, “Drawing and painting was useful too, but we didn’t really do it very often, although what we did was useful.” Art materials are used as props and mediums to facilitate processes, interactions and imaginary games. Children are physically active and will move around and interact with the space in a way which adults will not, moving furniture to create hide-outs, dividing up the space with string or in Federico’s case installing a goal post and playing football. I feel that what has helped Federico has been a complex approach that was specifically tailored to his needs in the here and now, ignoring the mind’s theory of ‘what you should be doing’, and responding to what ‘felt’ resourceful in the body. The two key healing factors identified by Federico himself are ‘playing football’ and the ‘receiving of a gift’. The former could be theoretically demeaned as a form of resistance to using the art materials. The latter could be theoretically challenged as unethical and an abuse of profession. Yet they are the key healing factors in this case. Trauma is a boundary that has been broken. Federico has taught me that if I wish to heal trauma, I must have the courage to break my own boundaries.

Afterword: living testimony The recorded interview used as a basis for this article was conducted during a therapy session (just over two years into therapy). I explained to Federico (and his parents) that I wished to publish an article on our work as I believed we had made important steps forward that merited being shared with other art therapists so they could benefit from them. I asked Federico for his consent and suggested that he might like to contribute. I said that I felt his voice was important to ensure that the final piece honored and reflected his lived experience. He chose the form of a recorded interview that was later shared with his parents. Updates on the writing process, clarifications, choosing the illustrations etc have all taken place during therapy sessions. As a private studio practitioner, I made this choice so as to ensure that all conversations were held within a protected and controlled environment. In line with the theme of this article, our written collaboration formed another transgression of boundaries and I was well aware that this would have consequences that would need monitoring. Re-reading the final manuscript, I am struck by how the collaborative writing of this article seems to be itself the next step in the process begun by the murals in my studio and the ‘sky’ on the table. It offers an additional support with a new kind of solidity. I imagine that for a 13-year-old boy, a publication is symbolically an engraving in stone: indelible. I hope this publication has helped him fathom the conundrum by which his parents pay for my time and services, but that fee is disconnected from the affection and feelings that develop within the relational space. Since the writing and sharing of this interview, he has asked for periodic sessions together with his parents ‘because you know how to say things’. In Winnicottian terms, I believe it has helped him ‘use’ his space (Winnciott, 1974).

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Notes on contributors : Rivkah (Rebecca) Hetherington is an HCPC (UK) registered art psychotherapist who trained at Art Therapy Italiana (Italy). Her particular interest in treating trauma has led her to specialize in the Clay Field and Guided Drawing at the Institute for Sensorimotor Art Therapy (Australia) and to train in Somatic Experiencing. She is an artist with a BA and MA in Fine Art in the UK where she grew up, and she has recently graduated in Psychology (Italy). Her home is Bologna where she has lived for 20 years and where she has her private practice, working with children, teenagers and adults, expanding on-line since the outbreak of COVID-19. Her interest in social justice has led her to create projects for Art Therapy Groups with Bologna women’s prison and for vulnerable teenagers in collaboration with child refugee centres, schools, cooperatives and social services. She offers pro-bono services for Bologna’s Women’s Shelter. In collaboration with Bologna’s LGBTQI+ centre, she set up an Art Therapy Group dedicated to LGBTQI+ service users and has published her research in this field (The Arts in Psychotherapy and IJAT). She firmly believes in Amber Gray’s ‘reciprocal alliance’ approach and is passionate about making art therapy available to everyone. arteterapia.rebecca@gmail.com

Federico Gentile is the pseudonym of the young boy who has generously contributed to this paper. He’s a pre-adolescent who found art therapy unexpectedly useful and is pleased and proud to share his experiences. But Federico is not a coincidental name. He is also an important alter ego, a famous footballer and millionaire who makes regular appearances in imaginative games during art therapy sessions, sometimes as a teenage son, sometimes as a father of two boys, sometimes as an art collector, always as a gifted footballer and someone who won’t take ‘no’ for an answer. Federico is here to demonstrate how being a rebel spirit can be endearing and lovable. He shares many of the young boy’s life experiences as well as representing the fulfillment of his hopes and aspirations. A big thank you to Federico !

Acknowledgements: I would like to thank my supervisors whose feedback and support led to my desire to write this paper : Mimma Della Cagnoletta and France Fleury (Psychodynamic Art Therapy); Cornelia Elbrecht (Sensorimotor Art Therapy); Vijaya Cinzia Conti (Somatic Experiencing).

The Version of Record of this manuscript has been published and is available in: INTERNATIONAL JOURNAL OF ART THERAPY : JUNE, 2022 https://www.tandfonline.com/doi/full/

Visit Rivkah’s website:

https://en.arteterapiabologna.org/

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