42DOI 10.24412/2713-184X-2021-2-39-47
ECOLOGICAL ART THERAPY TECHNIQUES IN THE PROCESS OF REHABILITATION OF THOSE WHO USE PSYCHOACTIVE SUBSTANCES
Oleg Bogachev
Head of the Department of Medical and Social Rehabilitation, "Center for the Prevention and Control of AIDS and Other Infectious Diseases" (St. Petersburg, Russian Federation)
Abstract. This paper presents the substantiation and results of the use of ecological art therapy in the rehabilitation of those who use psychoactive substances. The techniques of ecological art therapy are illustrated with examples from practical work in a day hospital and an outpatient culture and health club. The effects achieved in the process of creating art objects and installations from natural materials and photographing the environment testify to the versatile impact of this type of therapeutic work on the personality and mental state of individuals in rehabilitation.
Keywords: art therapy, clinical systemic art therapy, drug abusers, ecological approach, psychoactive substances rehabilitation
Introduction
Psychoactive substances include alcohol, opiates, cannabinoids, cocaine, sedatives and hypnotics, tobacco and others. There are various mental and behavioral disorders which arise due to the use of psychoactive substances (PAS), as well as psychotic disorders, such as withdrawal symptoms, short and long-term memory loss (amnestic syndrome), emotional and social disorders. Such disorders arise as a result of predominantly long-term, repeated use of psychoactive substances, leading to the formation of dependence and harmful consequences for the person's physical and mental health, as well as social adaptation.
Despite certain differences in the pathogenesis of the disorders of this group, they are all the result of a complex interaction of the biological factors, the psychological vulnerability of the individual and the influence of environmental factors. Intra-psychic, personal prerequisites for the development of dependence on psychoactive substances and the negative consequences of their use include difficulties in establishing contact with others, anxiety, lack of coping mechanisms, dysfunctional psychological defenses, and an increased level of aspiration combined with insufficient opportunities to achieve goals, among other factors.
Some of the interpersonal and social factors that play a role in the development of these disorders include increased psychosocial stress, and abnormal microsocial and social environments that are characterized by increased use of psychoac-tive substances or aggressive imposition of their use. Different subjects and communities have different levels of resistance to the use of psycho-active substances and the development of negative consequences associated with their use. Factors which affect this resistance include cultural norms and attitudes, how behavior is regulated internally and externally, emotional processes and psychosocial support.
Existing treatments for substance abuse and the mental and behavioral disorders that occur due to their use include biological therapy and various psychological and psychosocial interventions, which can be carried out with individuals, families, groups and entire communities. As a rule, in addition to the relief of acute disorders of physiological and mental functions associated with the substance abuse, more or less long-term rehabilitation and preventive measures are required to ensure the restoration and support of psychosocial functioning and increased resistance to repeated use.
Psychological and psychosocial interventions can include different forms and methods of work.
However, behavioral (cognitive-behavioral) and holistic approaches, often used in combination with the therapeutic community factor, are the most common approaches employed today. The emphasis is placed on the formation of a complex of life competences and coping skills that provide more successful social adaptation and resistance to use, support for self-esteem, and that strengthen the existential and spiritual foundations of the personality.
The experience of using art therapy and creative arts therapies in general (music therapy, dance-movement therapy, drama therapy, expressive arts therapy, in addition to art therapy) in this group of disorders indicates the significant possibilities of these methods in achieving stable remission and solving the complex tasks related to the re-socialization of drug abusers. It is noted that creative arts therapies have certain advantages in their treatment and rehabilitation. Foulke and Keller [10] point to the insufficient effectiveness of using some traditional forms of psychotherapy with drug addicts which involve increased confrontation, and associate this with the increased vulnerability of such patients in interpersonal contact and rigid defenses. These authors emphasize the value of art therapy methods as they allow the treatment process to be carried out in a 'softer' and less confrontational way.
Adelman and Castricone [7] emphasize the value of art therapy as one of the means of overcoming social isolation, since it provides an opportunity to use non-verbal means of communication as psychologically safer than verbal communication. Cantoper [9] notes that art therapy allows one to overcome defense mechanisms in the form of denial of problems, intellectualization and suppression of difficult experiences.
The ability of art therapy to increase self-esteem and relieve the feeling of inferiority in persons burdened with alcohol and drug addiction has been indicated in several articles [8,11]. Based on the analysis of literary sources, Moore [16] comes to the conclusion that art therapy can be one of the most effective methods of drug addiction treatment, since it provides an opportunity to overcome emotional, cognitive and behavioral disorders characteristic of such persons (loneliness, low self-esteem, inability to openly and sincerely express feelings, etc.).
Currently, various models of art therapy are used in work with drug users, including analytical,
behavioral (cognitive-behavioral), humanistic models, as well as narrative, holistic and others. The use of an ecological approach in art therapy is still used very rarely, although it has significant potential. Some of the advantages of using ecological art therapy with drug users are as follows:
• Ecological art therapy has a wide-ranging impact on different mental processes (sensations, perception, thinking, emotions, will power, behavior);
• It creates an atmosphere of greater psychological safety in comparison with many other forms of psychotherapy. This safety is linked to the possibility of maintaining optimal psychological, interpersonal distance in relationship to helping professionals and others. The atmosphere also encourages the creation of and interaction with environmental metaphors;
• It provides the possibility of reconstructing and harmonizing various disturbed personal relationships (with oneself, nature, other people, social institutions, etc.) on the basis of interaction with the environment, which provides a wider context in which these relationships can be perceived and actualized. It encourages awareness of the transpersonal, existential and spiritual levels of experience in relation to the self and others;
• It stimulates creative environmental activity as a form of coping behavior that strengthens protective and adaptive mechanisms.
This approach was carried out on the basis of the model of clinical systemic art therapy (CSAT) [2, 3], which provides a holistic overview of various factors of pathogenesis and treatment including biological, social, psychological and environmental factors and the relationship between them.
Conditions for conducting ecological / nature-assisted art therapy
Ecological art therapy was carried out with clients undergoing inpatient rehabilitation at a rehabilitation center (RC) and later involved in the activities of an outpatient culture and health club (CHC). Since 2015, art therapy programs have
also begun to be carried out at a day hospital (DH) organized by the Department for Counteracting Drug Addiction at the St. Petersburg Diocese of the Russian Orthodox Church.
There is a multi-professional team, including five clergymen of the St. Petersburg diocese of the Russian Orthodox Church, four mental health workers specialized in art therapy, gestalt therapy, positive psychotherapy, and group therapy working on the basis of the day hospital. They also serve as drug addiction consultants, organizing the process of completing written assignments and working with codependent relatives as well.
Mostly people aged 30 to 60 who have problems with the use of psychoactive substances take part in programs based at the day center. The majority are alcohol-dependent (70%); the rest are drug addicts in remission. Approximately 10% of the total number of rehabilitated people use the so-called new drugs (salts, acids, hallucinogens). Men make up about 80%, women about 20% of those who are being rehabilitated.
Art therapy programs based at the DH and CHC are designed primarily for group use. The dynamic nature of the group is strengthened when conducting sessions on the basis of a rehabilitation center with limited periods of stay, and is less strong when using CSAT at the CHC and other outpatient sites due to the more open nature of the groups. The themes of the sessions are related to the current requests and problems of the participants. The number of people attending usually varies from 10 to 20 people.
Over the past year and a half, programs operating at the CHC and DH have begun to more actively use the techniques of ecological / nature-assisted art therapy based on the principles and methodology of systemic art therapy, new ideas about the therapeutic environment, and the concept of the "Green Studio" as a special form of therapeutic space [4,5,12,14]. Increased attention was paid to the development of various social and personal skills and qualities associated with interaction with the natural and man-made environment on the basis of creative environmental activities such as the creation of art objects from natural materials, drawing from nature, taking photographs of the environment, body-oriented practices, and others.
The creative environmental activities used in the sessions combined symbolic means of self-expression and the experience of direct physical
presence in the environment. Some types of environmental activity involved focusing on somatic phenomena in the process of interacting with the environment, helping to develop mindfulness.
Body-oriented warm-up techniques related to the development of mindfulness were often used, forming some basic skills necessary for performing more complex environmental activities. Such techniques included:
• basic relaxation techniques, based on breathing and focusing techniques,
• exercises aimed at increasing sensitivity to environmental stimuli and objects, attun-ement to the environment and its natural dynamics,
• walks in the fresh air, requiring attention to internal mental and somatic processes with simultaneous interaction with the environment.
Most of the ecological art therapy practices used in this study were associated with the three channels for the development of a subjective attitude to nature, in accordance with Yasvin's concept of ecological consciousness [6]. These include perceptual-emotional, cognitive, practical and action channels. Due to the various types of artistic and creative activity used at different stages of the ecological art therapy program ("warm up" stage, main activity stage, reflection and conclusion stage), all these channels and aspects of environmental experience were consistently and holisti-cally integrated throughout the program.
Using the practical channel, the participants, for example, developed their skills to interact with natural objects and the environment, first of all, through their artistic and creative activity. These included both passive, receptive types of interaction, such as aesthetic perception of natural objects and meditative / mindful absorption in the environment, and active, expressive types of interaction such as taking photographs, making environmental drawings and botanical arrangements from found objects, creating environmental sculptures, etc.
The principles of ecological art therapy which formed the foundation of the program's approach were as follows.
1. The approach is person-centered and pays special attention to changing and developing clients' relationships to nature, their environmental consciousness and
environmental sense of themselves, their relationships to family, their work and professional activities, social and cultural environment etc.
2. It works through various channels with the aim of developing a subjective attitude to nature, including the perceptual-emotional, cognitive, practical and action channels [6].
3. It supports clients' capabilities to interact with natural objects and the environment both receptively through contemplation and meditation on natural objects and environments, and more actively through creative environmental activity and taking care of the environment (photographs, drawings, objects, landscape sculptures and design, etc.).
4. It encourages the development of objective-aesthetic and subjective-aesthetic attitudes to nature, which can complement or be opposed to the pragmatic, consumeristic attitude. This principle is associated with attention to the aesthetic expressiveness of nature, the development of the participants' ability to directly comprehend natural objects and the environment on the basis of their increased aesthetic sensitivity, to perceive and convey aesthetic attributes of natural objects and environments (color, shape, proportions, rhythms, sizes, symmetry, sound, smells, kinesthetic reactions, etc.). While an object-aesthetic attitude to nature implies the perception of nature as made up of "objects", a subjective-aesthetic attitude to nature implies its perception as a subject and suggests an intersubjective quality of clients' interaction with the environment.
5. It supports the participants' development of an eco-identity, which is associated with their experience and awareness of themselves as "ecological beings".
6. It encourages and develops empathy, identification with and subjectification of natural objects during clients' interaction with natural objects and environments, and cultivates their subjective attitude to nature.
7. It involves existential and spiritual factors associated with needs, values and meanings that go beyond consumeristic
attitudes towards nature and support a non-pragmatic, aesthetic and ethical attitude towards nature.
These principles of ecological art therapy provide a wider context for clients' self-perception and their relationships to nature, draw their attention to various elements of the global ecosystem, the need to take care of their well-being and their relationships to social and cultural milieu, people, and each other.
Ecological art therapy techniques used with clients with substance misuse issues
Plant and environmental arrangements
One of the forms of ecological art therapy practice used was the creation of art objects from natural materials and environmental installations. Often botanical arrangements in the form of "green mandalas" were made [15]. Natural materials were usually collected by the participants on the territory of the "Green Studio" [4,12,14], a therapeutic space, including not only an art therapy studio, but also a park environment (Metropolitan Garden) adjacent to the building where day the hospital was located.
The creation of art objects from the found natural materials, in addition to clients' interaction with the environment, maintained their interest in the natural and cultural landscape, relieved tension, developed their ability to experience beauty and to appreciate life in its diverse manifestations. This type of creative environmental activity also offered significant opportunities for the development of a sense of physical and emotional presence in the environment, stress relief, and sensory stimulation.
The creation of botanical compositions and environmental installations using natural materials and found objects took place at different times of the year. In some cases, the participants were asked to go outside and collect natural materials they liked while walking in the park. Returning to the studio, they created a composition out of them, for instance "a green mandala", using disposable cardboard plates as a base for their construction.
One of these sessions took place in the second half of September 2016. Having created simple
botanical arrangements from the found natural materials, while discussing the process and their mandalas, the participants noted that they enjoyed the beauty of simple things, and noticed the amazing diversity and harmony of the shades and forms created by nature itself. The beauty of natural forms had become more pronounced and recognizable for the participants through the process of organizing the found natural materials into simple compositions. Participants also noted that as a result of a relatively short walk in the fresh air (15-20 minutes), their emotional state had improved, and a feeling of joy and satisfaction from the activity had appeared.
Vladislav (name has been changed) (44 years old) said that his "green mandala" reflected his current state, which was rich in events, thoughts and feelings. He tied white flower-berries in the center of his composition and associated them with his wife, daughter and granddaughter (Fig. 1).
Everyone was satisfied with their work. At the end of the session, clients photographed their "green
mandalas" as a keepsake and went back to the territory of the park to sow acorns.
When the session was held in the winter season (February), despite the less comfortable conditions and limited natural materials, the participants were still able to gain valuable experience as a result of their work in the environment. They were able to create meaningful compositions from snow and found objects, reflecting their current state and relationships. The environmental practice evoked their current experiences and, at the same time, created a new context for reflection and understanding.
Yevsey (name has been changed) (37 years old) laid out a circle shape associated with his personal space, or a "house", out of snow and last year's leaves and placed a small snowman in its center. His comment on the work was as follows: "Looking at my snowman, I feel nostalgia for the past when I made a snowman with my son who is four years ago. Knowing that today's smiling snowman with a birch twig in his hand will soon melt,
Figure 1. "The green mandala" by Vladislav
I think about parting with my past life, and beginning some new, constructive relationships."
Lyudmila (name has been changed) (30 years old) titled her composition "Calm and comfort in the house" and commented on it as follows: "I perceive my creation as the beginning of life from a "blank slate." There is a house, and a hearth for my family in the very center. All positively charged energy is directed into the house. It is filled with calmness, joy, care and love. The walls of the house are strong. It is surrounded by twigs and leaves of oak and other trees. They support the house and connect it to the world of nature." (Figure 2)
Photographing the environment as a form of ecological art therapy
Another available type of art therapy practice that was implemented in the day hospital in accordance with the principles of ecological art therapy was photographing the environment directly adjacent to the building where sessions took place. During the course of the rehabilitation program, at different times in the year, the participants were repeatedly asked to go outside in order to photograph
any interesting natural and non-natural objects and places for about 30 minutes. In the process of photographing the environment and objects, the participants could also touch on some personally significant topics, such as, for example, "The environment as a metaphor of me", "My current issues and perspectives on life", "Memories and monuments of the past" and other themes that they formulated themselves. Sometimes the group leader suggested paying attention to certain objects in the environment, for example, to lilacs when they were in season in May.
After taking the photos, the participants could look at the created photos, choose some of the most meaningful images or create a certain sequence from them. In some cases, narrative techniques were used based on the photographs taken in the environment. The narratives were relatively short texts, an essay or a poem, written in a notebook either during the photo-walk or immediately after it.
When using this type of environmental activity, the significant possibilities of photography were taken into account, such as its capability to stimulate interaction with natural and man-made landscapes, to allow one to explore and change their attitude towards the environment. This type of creative environmental activity also allows one
to realize the meaning and beauty of the environment, it supports the personalization of the environment, and the development of personal and group identity based on meaningful connection with the environment. Viewing and discussing photographs also allowed participants to come to a better understanding of their past, present and future, and develop skills to describe their experiences in a coherent manner. Photographing the environment also provided significant opportunities for the development of a sense of physical and emotional presence in the landscape, stress relief, and sensory stimulation [5,13].
During one of the sessions in February 2017, it was suggested to the group participants to use the biblical parable of the Prodigal Son as a
metaphorical basis for the work. Roman (name has been changed, 48 years old) created a series of eight photographs, reflecting different elements of the environment, natural and man-made objects that caused both positive and negative reactions in him and which he associated with different aspects of his personal experience.
Looking through and then organizing the photographs in a series of images, including the most meaningful images that touched upon the physical, emotional and spiritual aspects of his experience, Roman chose photographs depicting a child touching a tree trunk, a branch of an oak tree with decayed leaves and an acorn protruding from under the melting snow, and a lush evergreen bush (Figure 3).
Another session, held in May 2018, began in the studio, where participants shared their feelings, emotions and thoughts about the past week's events. Then, the group leader drew attention to the blooming lilac, which was growing in abundance on the territory of the park and suggested a 20-30-minute walk through the places where it was blooming. At the same time, he recommended not only photographing the lilac bushes, but also making notes of the thoughts and feelings that arose when contemplating the lilac bushes and inhaling its aromas.
The group was then asked to read the text they had written, accompanied by photographs. At the end of the session, the participants noted the strong emotional impact associated with both walking and taking photographs, as well as performing their texts. They paid attention to the meaningful sensations, emotions and thoughts evoked through their contact with lilacs as an amazingly beautiful natural object that inspired the participants to create poetic texts.
Angelica (name has been changed) created this text:
May has come again And the lilac bloomed And in my soul, like a trill, I hear the voice of a nightingale.
The grass smells like honey The breeze has subsided a little, And the words come Like a prayer verse ...
My lilac paradise
Dear petal.
Give me hope
Like a call from childhood.
The sky smells like grass The sun's gentle ray Gives rare peace
From thunderstorms and clouds.
The wonderful smell is intoxicating; And the crimson chime Beckons behind him Into your lilac dream
Figure 4 . One of the photographs of lilacs created by Angelica
Conclusion
In this article, the rationale behind the use of ecological art therapy in the rehabilitation of people with substance misuse issues was presented, as well as some of the results of this work. Currently, different models of art therapy are used in work with this client group, including analytical, behavioral (cognitive-behavioral), and humanistic models. The ecological approach is still rarely used. Some of the advantages and results of the application of this approach in the process of rehabilitation of those who use psychoactive substances were shown and illustrated in this article with examples from practical work related to conducting sessions at a day hospital, and an outpatient culture and health club.
The above examples describe some forms of this work, which are relevant to the development of the promising area of ecological art therapy. The effects that were observed in the process of creating art objects and installations from natural materials and photographing the environment indicate the versatile impact of these types of work on
various mental processes (sensation, perception, thinking, emotions, will power, behavior), and demonstrate the opportunities for psychologically safe self-expression using environmental and natural metaphors provided by this approach.
The significant potential of ecological art therapy to harmonize the disturbed relations of the individual with themselves, nature, other people, society, and so on, was demonstrated. Creative
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