The title “therapy” and what do you do with it as a child? Recollections of being in child expressive arts group therapy

Abstract

The complexity of children’s entrance into mental health treatment has been the growing focus of much recent research. However, little attention has been given to the exploration of this phenomenon from the clients’ point of view. This study aimed to gain understanding of the experience of entering therapy as a child through examination of the recollections of adult former clients who had participated as children in expressive arts group therapy (EAGT). Semi-structured open-ended interviews were conducted with 20 adult former child therapy clients who had participated in EAGT for at least 1year. Two major themes were revealed: one concerning participants’ perceptions of the reasons for being in therapy as children and the other concerning their recollections and perception of their attitudes toward the idea of being in therapy. These two themes point to the central role of social, emotional, and cognitive developmental factors in the establishment of attitudes toward enrollment in psychotherapy, highlighting the difference between adults and children. These findings correspond with other studies in this area, adding a presentation of the experience from the client’s perspective.

Keywords

Expressive arts group therapy child mental health treatment qualitative research clients’ perspective stigma therapy motivation

Introduction

Expressive arts group therapy (EAGT) accommodates both children’s unique characteristics of peer-group involvement (DeRosier, 2004; Shechtman & Katz, 2007) and their tendency toward playful, experiential rather than verbal means of expression and communication, thus possessing high potential to enhance children’s motivation (Case & Dalley, 1989; Waller, 2003). With this, the process of referral of children to EAGT, as to other forms of child mental health treatment, remains complex, mainly due to the fact that most episodes of therapy are initiated by sources external to the child, usually a parent or another caretaker (Ollendick & Vasey, 1999; Weisz, Huey, & Weersing, 1998). The issues that matter most to the child may therefore be missed (Yeh & Weisz, 2001), and the very notion of therapy possibly may be experienced as alien.

As research on EAGT with children focuses largely on efficacy and effectiveness studies (e.g. Epp, 2008; Pretorius Pfeifer, 2010), little attention has been directed to such issues as the internal forces and processes at work when faced as a child with the intention of participating in therapy. This study endeavors to shed light on this unique aspect—understanding the experience of being in therapy when a child as seen through the eyes of adult former clients who participated as children in EAGT. By focusing on the memories of adults who were in therapy as children, this study allowed for the exploration of the sense made of being in therapy as a child from the clients’ point of view; how being in therapy was experienced as a child; and how this was understood in retrospect from the adult viewpoint.

EAGT with children

Expressive arts therapy (EAT) draws on the strengths of creative art modalities to elicit, amplify, or contain the therapeutic experience (Kim, Kirchhoff, & Whitsett, 2011). This type of therapy utilizes an integrated arts approach whereby the interrelatedness of the arts from various modalities is used in order to foster therapeutic processes (Malchiodi, 2005). Fostering children’s self expression through EAT has been found to be valuable in the group setting within which the sharing of feelings creates a sense of intimacy and belonging that serve to strengthen the cohesive forces among group members (Shechtman, 2002). Some recent examples of research showing the usefulness of these methods include studies and clinical reports such as those relating to their implementation in the treatment of sexually abused children (Pretorius & Pfeifer, 2010), in work with children from low social economic status (Jang & Choi, 2012), in improving social skills of children on the autism spectrum (Epp, 2008), and in work with pre-adolescents exhibiting behavioral and emotional problems (Bratton, Ceballos, & Ferebee, 2009; Kim et al., 2011).

Although providing valuable outcome information, these studies did not explore the important aspect of the lived experience and meaning of therapy as perceived by the child-client participants. In this way, the complexities of being in therapy as seen from the child’s point of view, which are possibly due largely to their not being self-referred (DiGiuseppe, Linscott, & Jilton, 1996; Yeh & Weisz, 2001), cannot be appreciated and fully explored.

Previous research on young clients’ attitudes to mental health treatment

To a large degree youth psychotherapy developed historically as an adaptation of adult mental health treatment (Frankel, 1998; Zack, Castonguay, & Boswell, 2007). In recent decades, however, the expansion of research in this area has led to the growing recognition of the crucial role of child development in the treatment of child and adolescent mental health problems (Kazdin, 2004). Today it is accepted that greater integration of child development principles with child-specific theory is needed in order to address complexities unique to youth (Shirk, Karver, & Brown, 2011; Zack et al., 2007).

One of the major factors found to affect the establishment of the conditions for psychotherapy is the working alliance (DiGiuseppe et al., 1996). The most commonly used conceptualization of the alliance is Bordin’s (1975) trans-theoretical definition which includes three major components: a bond, an agreement on the tasks of therapy, and an agreement on therapy goals. The quality of the alliance established through these three components would be expected to have great effect on the attitudes adopted by the child-client toward being in therapy (Yeh & Weisz, 2001). When relating to children, however, Barodin’s component concerning the individuation of goals has failed to be fully supported (Zack et al., 2007). Reasons for this remain unclear and further research assessing the components of the youth alliance is warranted.

Together with the quality of alliance established at the onset of therapy, the attitudes child and adolescent clients hold toward change would seem to be another important factor affecting their general attitude toward being in therapy. Prochaska and DiClemente (1986) proposed a model of the attitudes people have toward changes. In the first pre-contemplative stage, there is no desire to change. In the second, contemplative stage, willingness appears to explore whether change is desirable; in the action stage, concrete steps are taken toward change, and finally, in the maintenance stage, an attempt is made to consolidate the changes established. It seems that most self-referred psychotherapy clients seek help in either the contemplative or action stages. Because youths are usually not self-referred for therapy (Hawley & Weisz, 2003; Yeh & Weisz, 2001), the insights usually assumed that self-referred clients have accomplished, are lacking in children and adolescents (DiGiuseppe et al., 1996).

Yet another major issue of concern when considering young clients’ attitudes toward therapy is that of stigma and embarrassment toward mental health treatment (Gulliver, Griffiths, & Christensen, 2010; Oetzel & Scherer, 2003). The perception of mental health stigma includes the belief that individuals with mental health disorders are perceived as weak, flawed, dangerous, and socially incompetent (Wahl, 2003). In a systemic review of the barriers faced by young adults seeking mental help, stigma and embarrassment emerged as the most prominent (Gulliver et al., 2010). In the area of child mental health, the label “mental illness” was found to have a significant negative impact on the willingness of the North American public to socially engage with children with mental health problems (Martin, Pescosolido, Olafsdottir, & McLeod, 2007).

Although perceived public stigma presents a serious cause for negative attitudes toward therapy, studies focusing on college students found that the link between perceived public stigma and willingness to seek counseling was fully mediated by self-stigma (Vogel, Wade, & Hackler, 2007). These findings stress the importance of the individual subjective experience rather than external factors in determining participation in therapy.

Understanding the way children receiving therapy perceive social attitudes toward mental health and exploring how they might bridge the gap between self and social stigmatization therefore become an area worthy of examination. Moreover, providing a closer look at young client’s attitudes toward change, the setting of goals and agreement on the tasks of therapy, may also be of value. Such information calls for a more qualitative approach of examination, the use of which is well-documented in research methodology literature in relation to the exploration of processes in psychotherapy (e.g. Smeijsters & Cleven, 2006).

In this study, such a qualitative approach is presented which aims to shed light on the meaning of participating in EAGT when a child, as seen through the eyes of those who had experienced this themselves. By focusing on the memories of adults who were in therapy as children, this study allowed for the exploration of the sense that was made of being in therapy as a child; how being in therapy was understood; and what feelings were connected to this, both in their lives as children and from their viewpoint, insights, and understanding as adults.

Method

Participants

There were 20 participants in this study, 10 men and 10 women whose ages at the time of the interview ranged from 18 to 38 years. As children or adolescents they all had participated in EAGT for at least 1 year. The average length of therapy was 2.05 years and the age at the time of referral to therapy ranged from 8 to 16 (M = 11.15, standard deviation (SD) = 1.5) years. Of the 20 participants, 11 were young children (under 12) when enrolled in therapy and 9 were pre-adolescents and adolescents (above 12).

The main reason for which participants were referred to EAGT when they were children was their presenting with various degrees of social problems such as exposure to bullying and other social discomforts. All participants had been referred for therapy by their parents.

Procedure

The participants were recruited through a connection established with Misholim (“Pathways”)—The Jerusalem Expressive Therapy Center for Children. For over 30 years Misholim has been serving children, from infancy to 18 years of age, presenting with social, emotional, and behavioral difficulties. The therapy is long-term, open, and non-directive in nature. Weekly meetings (90 minutes) are held in closed group settings. Each group is run by two expressive arts therapists and includes four to eight children of the same age group.

The study was approved by the human ethics research committee of the Faculty of Social Welfare and Health Science, Haifa University. The names and contact details of participants were located through the archives of Misholim containing records of all clients who had been enrolled in therapy over the past 30 years. Contact with each participant was initiated by a member of the therapeutic team of Misholim who was not involved directly in the participants’ therapy. Theoretical sampling was used to achieve the widest possible sample (Lincoln & Guba, 1985). Maximum variation was sought: participants were from both genders, different ages, had participated in different therapy groups run by different therapists, and were from a variety of socio-economic backgrounds. Of the participants contacted, two did not give their consent due to technical inconvenience and therefore were removed from the research. Participant recruiting ended when theoretical saturation was reached (Padgett, 1998).

After obtaining the consent of the participants, their names and contact details were imparted by Misholim to the researchers. Researchers were not exposed to any other information pertaining to participants (diagnosis, etc.) beyond what was shared in the interviews. This seemed of particular importance since the first author, who conducted the interviews, is herself an experienced expressive arts therapist and so already prone to preconceptions concerning the therapeutic process.

All participants agreeing to be interviewed signed an informed consent to participate in the research, and the location of the interviews was chosen by them. Data were collected using semi-structured interviews employing open-ended questions (Britten, 1995). Each interview lasted between 45 and 90 minutes. All interviews were audio-recorded and later transcribed. For ethical reasons, the participants’ names were all changed, as were any other details which might have revealed their identity.

Data analysis

Data were analyzed following the phenomenological paradigm (Giorgi, 1975; Polkinghorne, 1989), sentence by sentence, often word by word, in order to identify main categories and sub-categories in the process. Analysis of the first interview influenced the data gathered in the second interview and so on. This recursive process allowed alteration and adding of hypotheses, ensuring findings emerged truly from the data.

Content analysis was applied as proposed by Strauss (1987) aiming to reveal core categories of meaning. Analysis included four stages: open coding, axial coding, selective coding, and core category. Open coding was performed to enable the development of content categories for each interview. Subsequently, cross-case analysis was performed by identifying themes that cut across interviews. Finally, units of meaning were identified and grouped into major themes and subthemes and from these core categories were identified. In this way, analysis allowed the buildup from the reading of individual cases to the theorizing of themes at a group level.

Peer debriefing (Denzin & Lincoln, 2000) was conducted by two auditors, well familiar with qualitative methods, who read through the analysis and traced references back to the original data to check their accuracy and to confirm that the analysis was adequately supported by the original data. Additional credibility by peer debriefing was achieved through colleague discussions which broadened researchers’ insights. Further validation was achieved through contacts with participants, discussing the results, and providing them with the opportunity to review and comment on a summary of the results. Of the 12 participants who complied with this procedure, none responded with any divergent perspectives. For various reasons including traveling abroad or military service, eight of the participants were not contactable.

Findings

In-depth interviews were conducted covering a large range of areas (e.g. the therapeutic process and the outcome of therapy), some of which have already been reported elsewhere (Diamond & Lev-Wiesel, 2016). This article will only present the findings most pertinent to the question of the participants’ perceptions of their attitudes toward being in therapy as children.

The findings which emerged relate to two major issues: one concerning participants’ perceptions of the reasons for being in EAGT as children and the other concerning their recollections and perception of their attitudes toward the idea of being in EAGT as children. A detailed portrayal of each of these sections and the themes pertaining to them will follow, accompanied by selected quotations. The quotations will be referenced in the following way: (Lia.9.F), meaning that the quotation is from the interview with “Lia” (all names are changed), aged 9 years at the time of being referred to therapy, female.

Perceptions of the reasons for being in therapy

Participants’ descriptions constantly shifted in the interviews from their recollections of themselves as children or adolescents to their perspective today as adults. The themes emerging in relation to the issue of reasons for being in therapy were found to cluster around the various developmental stages to be found in this study—that of the young child, the adolescent, and the adult.

My mom told me there were some kind of goals but it didn’t interest me too much

Appearing in the findings as typical to those who were in therapy as young children are recollections of their rather untroubled attitudes toward the goals and reasons for being in therapy. Most prominent in the recollections of these former young child clients is their attitude to therapy as a place of play and fun:

It didn’t feel so much like therapy. It felt to me like something between an art class and a social gathering.[. . . ] In “Misholim” Perhaps they did something very smart by not talking to us about how to be and how to behave in the group, rather they just let us be together naturally and in a good atmosphere and without judgment. It didn’t feel like therapy—it really helped. (Ruth.11.F)

But it’s like it [the therapy] all happened without me noticing, as if on its own and until now I didn’t say “WOW!” they [the therapists] were the ones who created in me such a serious change and stuff. [. . . ] For me personally, I think it was really good that I was not aware of the whole thing and it happened naturally without me noticing. The whole point is that you’re inside, you are in the picture and you don’t sometimes step out and observe. (Dvir.9.M)

Adolescents—when reasons for therapy did matter

As opposed to those who were in therapy as young children, among those who were referred as adolescents, great concern and interest in the reasons for being sent to therapy appeared in the findings. As will be presented, what emerged as most concerning to these former adolescent clients was their agreement or disagreement with the adults involved in the decision concerning their enrollment in therapy:

Disagreement

Among those who recall attitudes of disagreement toward going to therapy, the major concerns were the very fact of adults deciding on their behalf and intervening in their problems, as in the following examples:

I began therapy, not really out of my own will. My parents actually decided on it. I didn’t really like the idea but I was a kid I had to do what they said. Dealing with a new therapy setting, and for a long time, and it felt like a financial burden on my parents, all these are things that are not pleasant. I see other people get a cellular phone for three thousand shekels and I get therapy for three thousand shekels, so I don’t want this, I want that. (Ron.16.M)

The minute they give you something that will help you, that’s therapeutic, [parents tell you] it’s someone professional, so immediately there is this disregard: “I don’t need it. I can deal with it alone.” I think it’s from that that I thought I don’t need to be there. (Naomi.14.F)

Agreement

Adolescent former clients who recall agreeing to therapy seemed to emphasize their active role in taking this decision together with the adults involved, as in the following example:

Yes, I knew there were some problems with me socially and I didn’t think everything was fine with the situation I was in. I thought “therapy” is the word for the solution to the problem. It’s possible that it was actually the fact that it was “therapy,” maybe that’s why I agreed [with my parents] because it’s a more powerful act in terms of solving my problem. (Uri.14.M)

In some instances, they relate the decision solely to themselves, although in actual fact parents were also involved:

My social problems began to develop [. . . ] so I said that’s it, I’m pretty sick of this, I want to do something about it and so I joined the therapy group. (Shahar.16.M)

Why was I in therapy as a child? Looking back as an adult

This section will be devoted to themes emerging from the interviews relating to the understandings and reflections of participants concerning the goals and the suitability of the therapy they went through as children, as viewed from their standpoint as adults looking back. These issues came up typically in the interviews in which participants recalled certain unease or frustration about being in therapy as children which they could not articulate at the time. Looking back as adults, they give voice to their retrospective understandings, questions, and doubts.

Social problem as major problem—indeed?

In their efforts to understand what stood in the way, causing unease or frustration with therapy, several participants turned to reflect upon the nature of their emotional problems as children. Of most concern to them was whether their major, most prominent, and urgent emotional problem, that which had the most meaningful effect on their well-being, was indeed in the social realm or whether the heavy mass of its weight lay elsewhere. Questions were raised as to the suitability of their participation in group therapy. The following will present two out of several elaborations on this central question.

Social problem as a major problem or secondary to dysfunctions in parent–child relationship?

Leora affirmed having had clear social difficulties. The question she posed related to the ongoing source of these difficulties, and in relation to this, whether the therapy needed to focus primarily on the social aspect, the peer group, or rather on the family:

I didn’t see the connection between the fact that I was shy with people and that my dad yelled at me. It’s the fear that someone will come and knock me down and the fear from my father it’s the exact same fear, in the sense that it’s the same feeling. But I did not see the contradiction in that here—my dad yells at me and sends me to therapy so that I’ll be open to society and not afraid of such screaming at me from people. (Leora.14.F)

The identified patient

Lia described how the very act of sending her to therapy, from a framework of problematic family dynamics, positioned her to be pointed at as the source of all her family’s’ problems:

I think they [my parents] really thought that a family could be corrected through the children and especially through me. I was a complex child, I’m not denying, but I do not think that I was the biggest problem of my family, that’s for sure. [. . . ] My mother had these unfitting statements like: “I wish you were like that girl” or “Why you aren’t like this girl?” [. . . ] It was very clear that the most perfect product that could come out of the therapy was that a different child would come home. It was said, it was very much said. But maybe she [my mother] needed to go to art therapy? (Lia.9.F)

Attitudes toward the idea of being in EAGT as a child

Two major themes emerged from the findings in relation to participants’ conceptions of being in therapy as children—one concerning attitudes toward the title “therapy” and the other concerning attitudes to belonging to the therapy group.

The title “therapy” and what do you do with it as a child?

When discussing the experience of being in therapy as a child, many participants referred to the trouble they had fitting the concept “therapy” into their world. Following are descriptions of the various attitudes participants held and methods they contrived to deal with the challenges of being in “therapy” as children.

How to live in peace with the definition of “therapy?”

I was fine with it but I didn’t tell anyone it was therapy

Most participants reported to have not had much trouble accepting their going to therapy themselves, but they did find it necessary to conceal this from others:

It was a secret bottled inside me. I did not start to talk with my friends from school about my being there and being happy there and that. (Yossi.9.M)

It was something I didn’t tell people. I wasn’t ashamed of it, I just knew that people would not understand what I was doing there and I would just be seen as a much more problematic guy and it would just create a bad image for me. (Shahar.16.M)

Simply changing the title

Some, like Dror, reported that they simply found a different title, such as art class:

I don’t think they [my parents] hid from me the reasons or what it was all about, but still I thought of it as a kind of art class. Like once a week, that’s how I presented it to my friends, a kind of class in “Misholim.” [I said]: “I meet with friends. We meet together, paint, play with pillows [. . . ] we have fun.” And really that’s the way it was perceived by me. (Dror.9.M)

Better not knowing

One participant, Dvir, reported recalling not being aware at all as a child that it was therapy he was attending. In retrospect, Dvir saw this as a positive thing:

I think it was better that I was not aware of it [that it was therapy]. For me personally I think it was really good I didn’t know about the whole thing. [. . . ] for a child it’s very demeaning, I think, when you say to him that he’s problematic and he needs therapy and he doesn’t understand you’re trying to help him. (Dvir.9.M)

When no way is found to live in peace with the title “therapy.”

Few participants reported that as children they had not found a way of accepting being in therapy. One of them, Naomi, saw this in fact as the main reason for her early departure from therapy:

I knew it was therapeutic. I knew it was supposed to help me in some way. I don’t think at that point I knew to what it was supposed to contribute, but just the fact that I was told you are now going to therapy, it will help you, psychologically I didn’t want it. I didn’t want to feel weak and that I need therapy and that something is wrong with me, but that something is wrong with the world. (Naomi.14.F)

Attitudes toward belonging to the therapy group

Participants in this study were sent not simply to “therapy” but to “group therapy.” The added element of the “group,” as will be seen in the following quotations, set yet another challenge to be dealt with.

When difficulty meets difficulty: do I belong to this group?

Several participants related to their experience of encounter with the group as arousing feelings of aversion. They related to their experience of considerable gaps between themselves and other members of the group in terms of the severity of their difficulties and how this evoked uncomfortable feelings of shame:

What I do remember is that I looked in a negative way at the people who were with me in therapy; I was ashamed that I was part of a group like this. I remember this clearly. How do you say? I just felt disrespect for the people who were there. (Ofek.12.M)

When difficulty meets difficulty: it’s not that I’m the only one who has problems

In complete contrast, other participants related to their experience of encounter with other people with difficulties as one arousing feelings of acceptance and belonging:

We were several children in the group and started therapy. [. . . ] I met a lot of people there who, as children [. . . ] are like me, everyone comes with their story and their problem. It’s not that I’m the only one who says that she has problems, difficulties. I mean, everyone comes with their story, and I came with my own special story. (Gili.12.F)

Discussion

Through their detailed reports, participants in this study provide us with both their recollections of the experience of therapy as children or adolescents and also their retrospective understanding of the meaning of this experience. Although by no means an accurate account, but also not a complete distortion, these reports can be seen to offer glimpses of the attitudes toward participating in child EAGT from different developmental stages—that of the young child, the adolescent, and finally, the adult looking back.

Immersion in fun and play with little consideration of the reasons for therapy among those who were in therapy as young children emerged prominently in the findings, as can be seen in the theme My mom told me there were some kind of goals but it didn’t interest me too much. This corresponds with studies referred to earlier (Zack et al., 2007), concerning Barodin’s working alliance model, whereby the component of goal individuation failed to be fully supported in the case of children. As a possible explanation, children’s less developed cognitive abilities are referred to (Zack et al., 2007), which limit their ability to meet the variety of cognitive skills necessary in order to articulate long-term therapeutic goals. These include the capacity to think hypothetically and instrumentally, to generalize outside the therapeutic setting, and to delay gratification.

In contrast to younger children’s characteristic limited concern with therapy goals, in the theme Adolescents—when reasons for therapy did matter, a glimpse may be caught of the attitudes among those who were in therapy as adolescents and it is possible to observe how they appear most preoccupied with concerns about the goals and tasks of therapy. This agrees with studies relating to adolescent’s developing cognitive capacity for abstract thought and socio-emotional development that causes them to be more sensitive to issues of dependence and independence (Oetzel & Scherer, 2003)

Continuing on the developmental sequence, the theme Why was I in therapy as a child? provides us with the viewpoint of participants looking back today as adults at the therapy they went through as children. Prominent in this theme is their concern with issues of the suitability of therapy. Unlike in the themes relating to former adolescent clients’ attitudes to therapy, and in complete contrast to those concerning former clients who were young children, the theme depicting the view of adults is filled with insights and complex understandings of the reasons for therapy. Although having the added advantage of the perspective of time, the adults’ viewpoint stands out in its sophistication, implying a sense of looking at the whole picture. Several of the participants whose ideas are presented in this theme convey the sense of frustration about having been sent to therapy. Looking back as adults, it has become possible to articulate, justify, and explain the frustration they felt as children who lacked the tools to express their feelings clearly.

Juxtaposed against the sophistication of the adult attitudes toward having been in therapy, the unarticulated attitude of the young child, as emerge in the findings, might seem limited and confined. Are children to be seen as limited versions of adults in regard to the establishment of goals and the understanding of the reasons for being in therapy? Historically, child therapy techniques developed as modifications of techniques used with adults (Frankel, 1998; Zack et al., 2007). Should this be the case in relation to the establishment of children’s attitudes toward being in therapy, where the model set by adults points to establishing a working alliance through the discussion of goals and reasons for therapy? (Coyne & Widiger, 1978). Or perhaps, the developmental diversity, as it so clearly emerges in this study, calls for a different approach? Perhaps it is not only more difficult for children to understand the goals of therapy, but they also have less need for such formal constructions when the youthful flow of play and fun are still so easily accessible to them (Frankel, 1998).

Mental health treatment has long since been defined by Winnicott (1971) as “a highly specialized form of playing in the service of communication with oneself and others” (p. 41; italics added). As is stated by him, “Psychotherapy has to do with two people playing together” (p. 38; original in italics). Children are more able to be fully immersed in the “here and now” of spontaneous interaction (Vygotsky, 1967; Winnicott, 1971), a mode which often takes much effort to elicit in adult psychotherapy clients (Austin, 1999; Miller, 1997). The carefree attitude of children toward the goals and aims of therapy that emerges in the findings should perhaps be enhanced rather than adapted to fit the adult model, particularly in those cases where participants recall enjoying as children the activities involved in therapy. This notion is expressed by Landreth (2012) who claims that

In seeking to facilitate children’s expression and exploration of their emotional world, therapists must turn loose of their world of reality and verbal expression and move into the conceptual-expressive world of children. (p. 7)

It has long been recognized that the client’s motivation is a pivotal factor in psychotherapeutic treatment. According to Krause (1966), that is “because the psychotherapy patient . . . does not merely receive treatment but must actively participate in it, his motivation to participate is a vital factor in the outcome of treatment” (p. 9). In the earlier mentioned model of attitudes toward change, Prochaska and DiClemente (1986) stressed the importance of reaching a contemplative willingness to change. Although in this study such a conscious deliberate motivation appeared to have been lacking among those who were in therapy as young children, possibly a different kind of motivation was at play. In the case of psychotherapy, where internal change is the focus, the kind of motivation to be most strived for is intrinsic motivation which has been defined as the desire to engage in an activity purely for the sake of participating in and completing a task, as opposed to being motivated by external forces (Bates, 1979; Deci, Vallerand, Pelletier, & Ryan, 1991). Writers on the play of humans and animals (e.g. Bruner, 1972; Erikson, 1950) have agreed that play implies pleasure in an activity for its own sake, free from external goals, pressures, or threat. Play, therefore, is essentially an intrinsically motivated activity. According to Maslow (1954), an intrinsically motivated person acts out of an internalized desire to self actualize. In this way, in the case of children, enhancing children’s developmental ability to be immersed in free-flowing activity without lingering on the goals to be achieved might be greatly beneficial in enhancing their internal forces pulling toward growth and change.

Although conceptualizing only in a limited way the broad and often more abstract goals of therapy, in the theme The title “therapy” and what do you do with it as a child? the findings show participants’ sensitivity as children to the possible negative stigma of their social group toward their participation in therapy and their ability to devise various methods of dealing with such threats. This is a meaningful finding in light of the formerly mentioned crucial role of self-stigma in mediating the link between perceived public stigma and personal willingness to seek therapy (Vogel et al., 2007). Particular effort should therefore be invested in assisting those in need to prevent the internalization of social stigma by demonstrating how these may be managed.

It should be mentioned in this regard that in the efforts participants recall having made as children to deal with the negative stigma associated with therapy, the prominence of art, play, and fun within the therapeutic setting was much emphasized. In the theme How to live in peace with the definition of “treatment?” this tendency can be discerned most clearly in the recollections of participants of relating to therapy as an art class or describing it to friends as a place of fun and games. In this way, the positive, healthy aspects of joy, creativity, and play so innately part of EAGT (Kim et al., 2011) feature prominently to counteract potential negative, stigmatic attitudes toward therapy.

Concluding comments, limitations, and implications

While there is no doubt that the accounts of former child EAGT clients in this study are not “objective” records of what happened in the past, the sense that these former child clients have made of their experiences do provide a unique and much neglected perspective of the therapeutic encounter.

Aiming to explore the attitudes toward being in EAGT from the former child client’s perspective, this study highlights the unique way in which children relate to and deal with this often challenging encounter. Engagement in the activity involved in therapy with little concern toward the apparent therapeutic goals emerged as central in the findings, indicating particular contrast between the attitudes characteristic of adults, adolescents, and young children toward being in therapy. This distinct difference, apparent in the findings, is compatible with the growing recognition in the psychotherapy literature of the role of development in the treatment of child mental health problems, indicating that youth treatment must be directly studied within this population, rather than extrapolated from the more established adult psychotherapy literature (Zack et al., 2007).

The central role of development in the formation of attitudes toward therapy, apparent in this study, elicits questions concerning the unique mechanisms involved in enhancing child motivation toward being in therapy. This study points to children’s profound capacity to plunge fully into activities of play and fun as central in eliciting their implicit motivation to engage in therapy. The emphasis in EAGT on play and free-flowing creative expression can be seen in light of this as playing a vital role in enabling therapy to be both accessible and meaningful to the young client.

As stated from the beginning, this study was of an exploratory nature, and therefore, the findings can only be cautiously applied beyond the specific setting and group of participants from which they emerged. It tells only what the participants themselves believe and chose to report. Further research is needed in order to read these accounts within a broader context. Undoubtedly, comparing participants’ reports with those found, for example, within therapists’ case notes or parents’ reports would provide a wider perspective and deeper insight.

Yet another limitation of this study is that all participants were recruited from the same expressive art therapy center—“Misholim.” Research drawing data from a range of different settings would surely generate a richer picture. With this, the therapy groups explored were led by different therapists, providing an array of diverse therapeutic styles. The fact that the researcher conducting the interviews is herself an experienced expressive arts therapist also implies certain limitations. While she was thus armed with firsthand knowledge about this type of therapy, it also predicated preconceptions. However, in some respects, such a bias may also have its advantages since it made it possible to follow participants’ descriptions, picking up on meaningful issues and exploring them in detail.

Notwithstanding that generalization has imposed limitations on this study, implications for child EAGT are nevertheless meaningful as for therapists working in the field, it provides valuable firsthand information through which they might grasp something of the experience of being in therapy from the child’s perspective. The highlighting in this study of the centrality of developmental factors in the establishment of attitudes toward being in therapy may serve to sharpen therapists’ sensitivity and deepen their acknowledgement of the fact that children are not only less sophisticated but also simply different from the adults they will one day become.

Footnotes

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author biographies

Shira Diamond is a PhD candidate of the Interdisciplinary Department of Social Sciences, Bar-Ilan University, Israel and a graduate of the master’s degree program at the School of Creative Arts Therapies, University of Haifa, Israel.

Rachel Lev-Wiesel is Professor and Chair of the Emili Sagol Creative Arts Therapies Research Center and Founder and Former Chair of the Graduate School of Creative Arts Therapies, University of Haifa, Israel.

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