Art therapy as emotional

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Art Therapy as Emotional and Spiritual Medicine for
Native Americans Living with HIV/AIDS
Melanie B. Bien
a
a
Family & Child Guidance Clinic, Native American Health Center , San Francisco
Published online: 08 Sep 2011.
To cite this article: Melanie B. Bien (2005) Art Therapy as Emotional and Spiritual Medicine for Native Americans Living
with HIV/AIDS, Journal of Psychoactive Drugs, 37:3, 281-292, DOI: 10.1080/02791072.2005.10400521
To link to this article: http://dx.doi.org/10.1080/02791072.2005.10400521
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Art Therapy as E01otional and
Spiritual Medicine for Native
A01ericans Living with HIVIAIDSt
Melanie B . Bien, M.A., ATR-BC*
Abstract-This article describes the intricate challenges ofbringing mental health services to isolated,
guarded urban HIV-positive Native Americans suffering from chronic trauma-related illnesses and
imbalances, depression, anxiety, substance abuse, thought disorders and trauma-based
characterological disorders. It explores the integration ofart therapy. Bowen Family Systems Therapy
and in-home therapy in the Family & Child Guidance Clinic's attempt to provide support to a
population that has profound distrust for "services and treatment," and no historical context for
psychotherapy. Changing the paradigm of thought is essential to providing services that respect
culture and history as well as addressing current presenting issues. Art therapy and in-home therapy
support those community members who are flooded emotionally, but have difficulty speaking about
their internal processes.
Keywords-art therapy, Bowen Family Systems Theory, historical trauma, HIV, Native Americans,
substance abuse
The Native American Health Center (NAHC) is a com
munity-based clinic providing primary care, mental health
servcies and dental care to Native Americans that is lo
cated in San Francisco's Mission District. It began providing
HIV primary care in 1 987 and HIV nurse case manage
ment in 1993. According to HIV case manager Parousha
Zand, R.N., early case management efforts focused on "get
ting people to where they needed to be and assisting them
in medication adherence." The primary obstacles addressed
tThis work was supported by the Center for Mental Health Services
grant SM53893 (Native Circle). The contents of this article are solely
the responsibility of the author. Special thanks to the HIV Services
Department-Family & Child Guidance Clinic, San Francisco, for their
collaboration.
*Art Therapist, Family & Child Guidance Clinic, Native American
Health Center, San Francisco.
Please address correspondence and reprint requests to Melanie B.
Bien, email: melaniebien@gmail.com.
Journal of Psychoactive Drugs 281
were homelessness and isolation. As a result of intensive
NAHC outreach, by 2002, 90% of the HIV department's
case management patients were housed, 50% had received
some substance abuse treatment and medication adherence
was increased from 0% to 90%. As the primary needs of
food and shelter were being met, a foundation and climate
was created for providing mental health services to these
HIV-positive clients. The possibility of addressing the un
derlying emotional trauma and additional mental health
issues was significantly increased.
The Native Circle program is a five-year demonstra
tion project funded by the Center for Mental Health Services
(CMHS) in the Substance Abuse and Mental Health Ser
vices Administration (SAMHSA), with a primary objective
of developing a culturally competent mental health pro
gram for HIV-positive Native Americans. Nelson Jim
Volume 37 (3), September 2005
Downloadedby[OsakaUniversity]at01:1112November2014

Bien
(2004), Director of the Family & Child Guidance Clinic
(FCGC) within the NAHC, states:
The Native Circle program is the only American Indian/Alas
kan Native-specific program funded for the CMHS HIV
mental health initiative. Native Circle has established itself
uniquely as one of the most culturally competent commu
nity-based HIY mental health services in the nation. It has
implemented innovative mental/emotional/spiritual wellness
interventions to meet the needs of one of the most disenfran
chised and oppressed communities in America and Native
America: gay, bisexual, transgender, men who have sex with
men (MSM) and other individuals living with HIY/AIDS.
Through the development of culturally competent clinical
treatment, trauma has been recognized as the single most
pervasive phenomenon in the HIV+ Native Circle clients.
TRAUMA
In order to discuss the mentalhealth issues ofthis popu
lation and how the FCGC began to approach the work, it is
essential to first discuss the underlying historical and per
sonal trauma that most, if not all, of the HIV+ clients are
battling. Understanding the severe individual and collec
tive trauma that these patients have suffered is key in
establishing how to reach and support them. As explained
by Irene Vernon (200l ) in her research on HIV in the Na
tive community, underlying trauma is a predictor for
high-risk behavior and seriously impacts HIV transmission:
High rates of trauma, such as sexual molestation and domes
tic violence, are also present in many Native communities,
placing Native people at risk for HIY/AIDS. These traumas
are associated with depression, drug abuse and anxiety disor
ders, thus it is extremely important for Natives and AIDS or
ganizations to address the levels and extent of individual and
community trauma when they address HIV/AIDS issues and
concerns.
Personal and historical trauma later affect one's ability to
access medical care, social, and mental health support.
Additonally, these issues are exacerbated by high incidences
of substance abuse and in turn seriously impact attempts at
substance abuse treatment and its efficacy.
Literature is rapidly emerging describing the poignant,
lingering experiences ofthoseexposed to repeated, systemic
trauma. In her article, Ur. Maria Yellow Horse Brave Heart
(2003) describes this phenomenon:
Historical trauma (HT) is cumulative emotional and psycho
logical wounding over the lifespan and across generations,
emanating from massive group trauma experiences; the his
torical trauma response (HTR) is the constellation of features
in reaction to this trauma. The HTR often includes depression,
self-destructive behavior, suicidal thoughts and gestures, anxi
ety, low self-esteem, anger, and difficulty recognizing and ex
pressing emotions. It may include substance abuse, often an
attempt to avoid painful feelings through self-medication.
Journal ofPsychoactive Drugs 282
Art Therapy
Historical trauma speaks to a phenomenon larger than in
dividual childhood or adult experiences, affecting Native
Circle clients today. The very concept of historical trauma
recognizes the collective, generational symptoms ofpeople
whose identities and traditions were taken and who are
required to assimilate and adapt culturally, with serious
consequences for many community members.
A common trait of the Native Circle clients is isola
tion. Isolation is particularly painful for Native Americans,
whose heritage places great value on community and in
clusion. These clients have a long history of being cut off
from all that is essential to Native American life: the land,
spiritual practices and family. Addressing the isolation of
the Native Circle clients is crucial to their recovery pro
cess, both from mental health imbalances and substance
abuse.
Judith Herman ( 1 992) wrote extensively on the phe
nomenon and recovery process of trauma: "The core
experiences of psychological trauma are disempowerment
and disconnection from others. Recovery, therefore, is
based upon the empowerment of the survivor and the cre
ation of new connections. Recovery can take place only
within the context of relationships, it cannot occur in iso
lation." When HIV-positive Native clients began to receive
mental health treatment, it became evident that they were
managing complicated relationships to family of origin and
a traumatic cultural legacy. It was clear that an expansive
systemic thought process was essential to guide clients back
into balance.
FAMILY SYSTEMS ORIENTATION
The members of the Family & Child Guidance clini
cal staff are oriented in a variety of psychological
approaches and theories. Social work, somatic theory, psy
chodynamic thought, art therapy, and traditional thinking
are all valued and utilized approaches to healing and cre
ating balance. However, the overarching orientation of the
clinic is family systems theory. Integrating Bowen family
systems theory has been a way to think as a unified clini
cal team, respect individual disciplines and areas of
expertise, and address the broader experiences of Native
Americans in the United States. Components of Bowen
family systems theory are integral to how staff relate to
the ongoing struggles of the Native American community,
and more specifically, to HIV-positive Native Circle cli
ents. It is an understatement to discuss the lingering effects
of genocide, forced relocation, boarding schools, censor
ship ofculture, sexual and physical abuse, fractured family
systems and disrupted spiritual systems of thought and
practice as anxiety. However, Bowen Theory examines the
devastating effects ofany system (or culture's) experiences
in terms ofanxiety and explores its generational and physi
ological effects.

Bien
Bowen family systems theory is grounded in the study
of profound anxiety in an organism over time and the dra
matic effects that cumulative anxiety has on physical and
emotional well-being. Though not specific to NativeAmeri
cans, this theory is compelling in terms of the neurological
effects of historical trauma and how that relates to addic
tion, mental health and personal development. It also speaks
to the Native American experience offorced or "pressured"
adaptation to a larger European culture. Bowen's theory:
. . . addresses the interplay of different levels ofbrain devel
opment as expressed in the behavior of the individual. A key
variable is the level of demand to adapt to a changing envi
ronment. The more the pressure to adapt [italics added], the
greater the likelihood of the operation of automatic behav
iors or mechanisms that hinder the full potential of neocorti
cal functioning (Papero 1 990).
What this means is that historical trauma, and the pressure
to adapt over a long period of time can result in a limited
ability to respond or act from the executive functions of
the brain; individuals are responding more frequently from
limbic processes of the brain. These limbic responses are
automatic and /or emotional, which is the crux of contin
ued sustained substance abuse and other cycles of
self-destructive behaviors. Understanding trauma and anxi
ety and resulting brain functioning is imperative when
dealing with individuals who have experienced dramatic
shifts in culture and identity. In essence, historical trauma
creates profound anxiety and this anxiety impacts brain
functions that may inhibit the use of executive functions of
the brain.
Generational transmission of anxiety has long-term
physiological effects on cognition and behavior. This is key
to understanding the complex neurological factors at play
when treating the Native Circle clients, who have had per
sonal traumas that make them more vulnerable to the effects
of historical trauma. It puts into perspective their genera
tional trauma and its effects and what physiological and
neurological barriers might be at play in treating chronic
mental health and substance abuse. Bowen family systems
thinking observes broadly and over time. Generational
transmission of automatic emotional processes (such as
anxiety/trauma) effects current treatment efforts, and theo
ries that focus on individual pathology are not sufficient in
supporting and treating populations that have experienced
prolonged trauma and its effects.
Providing ways for clients to think about their indi
vidual experiences in the context of a larger system returns
them to the kind of traditional community thinking neces
sary to create shifts within the individual. What happens in
the larger system clearly affects the individual. What hap
pens individually, in turn, affects the system. Many of the
community members served at the FCGC are struggling
with deep automatic emotional responses to their cultural
Art Therapy
history through generational transmission ofanxiety symp
toms. Papero ( 1990) explains the physiological affects of
the stress process:
Anxiety can be defined as the arousal of the organism upon
perceiving a real or imagined threat. When so aroused, the
emotional system of the anxious individual tends to override
the cognitive system and behavior becomes increasingly au
tomatic. Subjective decisions based on internal feeling or af
fect predominate. People tend to act to relieve discomfort,
even though their decisions and behavior may lead to long
range difficulties and even greater discomfort.
This has interesting implications in relation to substance
abuse cycles. While these clients desire to overcome per
sonal and collective trauma and recover from mental health
imbalances and substance abuse, they may be facing neu
rological obstacles to well being due to that trauma. What
is most important is how to use this information to increase
functioning levels of the individual within the system.
APPROACHING THERAPY
Though clearly in need of emotional support, many
clients in the Native Circle program were found to be hesi
tant regarding therapy. The anxiety of facing their trauma
was greater than any rewards they could imagine. Recep
tivity to treatment is essential to doing therapeutic work.
In many cases this openness to therapy was missing, but
clients did demonstrate receptivity to human connections,
a neutral listener, and a nonjudgmental environment in
which they could relate their stories. The question was: how
does the agency work with this limited receptivity without
being intrusive? How does FCGC provide culturally ap
propriate services? In this case culture meant not only
ethnicity, but also the culture ofthe homeless, of substance
users, ofNative Americans who had moved fromrural res
ervations to dense urban areas, of SRO (single room
occupancy hotels) dwellers, ofMSMs, and ofgay, bisexual
and transgender persons. The FCGC goal was to accept
this reluctance and provide culturally appropriate mental
health services in ways that were creative, respectful and
sustainable.
BRINGING THERAPY HOME
Native Circle clients aremost frequently juggling acute
and chronic medical issues, emotional lability from man
aging a life-threatening illness, stress from long histories
of traumatic events, confounding clinical pictures due to
sporadic or ongoing substance abuse, co-morbid untreated
mental health issues, as well as fractured familial systems
and cultural issues. It can be overwhelming to know where
to begin. In 2001, the Family & Child Guidance Clinic
began to provide therapeutic home visits fortheHN patients

Bien
who were not making use of the therapeutic services at the
clinic. Most of these patients were not coming to their regu
lar medical appointments though many remained in phone
contact with medical staff. They often called in crisis for
case management support, acute medical interventions (like
abscess care or more severe HIV-related opportunistic in
fections) or for emotional support. It was obvious to both
medical and FCGC staff that there was a linkage between
underlying mental health issues and limited follow through
with medical care. Through the therapeutic home visits, it
was hoped that some of the blatant issues of depression,
anxiety and substance abuse could be addressed and pa
tients would seek medical attention sooner and more
frequently.
In the face of their many acute and chronic issues cli
ents themselves may not be aware that some of their
symptoms are specific, typical responses to living with ter
minal illness, and may be alleviated. The goal was to
encourage clients to seek medical attention when needed,
and assist them in gaining support for the relief of immune
system harming mental health issues, like depression.
Though these clients often had long histories oftrauma and
substance abuse, some of their symptoms were related spe
cifically to HIV/AIDS. The connection between mental
health issues and HIV is clear:
People with terminal illness such as AIDS usually experience
intense emotional states. These patients vacillate between an
ger, guilt, rage, depression, fear, and sadness. Their emotions
can fluctuate within the course of a day creating an exhaust
ing roller coaster effect. Mercurial swings between hope and
helplessness are sometimes due to alterations in their medical
condition (Bussard & Kleinman 1 99 1 ).
In this same vein, many Native Americans are struggling
with issues surrounding identity. Because this struggle is
ongoing for Native people, especially those who have moved
from rural reservation life to urban settings, identity issues
directly related to HIV/AIDS can be cloudy. In fact, it is
common for HIV/AIDS patients to struggle with existen
tial issues of identity. "One of the losses often experienced
by AIDS victims is the loss of individual identity. These
patients are living statistics whose self-image gradually
decays under the onslaught of personal losses" (Bussard &
Kleinman 1 991 ). For a community that is already trying to
emerge and define itself and its members against the back
drop ofgenocide and resulting trauma, the depression, grief,
and spiritual loss is compounded. Providing a version of
therapeutic support that acknowledges both remote and
present loss in the intimate setting oftheir own home was a
natural and useful first step to building trust and creating
an environment for witnessing, creativity and growth.
The initial therapeutic home visits had humble inten
tions: to decrease isolation ofHIV medical patients, to bring
them art materials, and to provide an environment that in
creases the possibility of receptivity to mental health
Art Therapy
support. The art media provided a less threatening means
for self-expression as well as a projective activity to re
duce anxiety and depression symptoms. Additionally, the
home visits provided a consistent and nonintrusive way to
assess a patient's acute needs and to encourage them to
receive medical attention (if needed), to discuss end oflife
concerns, and to assess and address other neglected men
tal health issues. The trust that grew out of these home
visits also created an avenue to monitor substance abuse
and an opportunity for discussion of harm/risk reduction.
ART THERAPY
Art therapy is an organized discipline of thought, with
roots in psychodynamic theory, that makes use of visual
images and art-making for selfexpression, insight and heal
ing. Art therapy theory contends that the expression of
creativity through art-making allows for metaphoric trans
formation of the psyche that can lead to changes in
behavioral and cognitive functioning. "It has been said that
the creative urges of humankind are universal and intu
ition is a primitive inheritance. The roots of creativity lie
in images constantly being formed, whether waking or
sleeping. The desire to project these images into symbolic
meaning is both strong and unrelenting . . . . This inner
creative force serves as a backdrop for healing" (Spring
1 993).
Current advances in neuroscience suggest further ad
vantages of art therapy in the direct treatment of trauma.
Linda Chapman and colleagues (2001 ) state, "Art making
assists in integrating traumatic effects through the bilat
eral stimulation of brain hemispheres and synthesizing
visual and verbal narratives into coherent traumatic auto
biographical memory." Her work suggests a biological and
developmental basis for the therapeutic mechanism. For
FCGC, art therapy is particularly relevant to the healing
process of Native Americans due to the historical and cul
tural context oftheir trauma. Native American people have
traditionally used art-making for both utilitarian and spiri
tual practices. Native beadwork, textiles, jewelry, clothing
and contemporary works of visual art reveal a rich heri
tage of utilizing the creative process for balance and
community wellness. Within this culture there is already a
context for the use of art as a pathway to healing and bal
ance. To reintroduce art-making to Native community
members who may have forgotten in theirminds what their
cells remember is intuitive. Bringing art as therapy to the
HIVIAIDS patients respects their limits and boundaries and
assists them in processing trauma while minimizing intru
sion on the defenses and coping skills they had put into
place for survival. For some, art was the medicine. The
following case illustration demonstrates a culturally ap
propriate blend of family systems theory and art therapy
with an HIV-positive Native client.
Volume 37 (3}, September 2005

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CASE ILLUSTRATION
Marcus (not his real name) is a 40-year old, gay, Na
tive American and Caucasian man. He was diagnosed with
HIV in 1 984 and received an AIDS diagnosis in 1993.
Marcus reports that his life was saved by protease inhibi
tors, and that he was in the hospital, "expecting to die"
when he took his first trial in 1 997. Marcus lives with
comorbid hepatitis C (HCV), alcoholism and opiate addic
tion. His ongoing somatic complaints include severe
neuropathy, nausea, night sweats, fatigue, insomnia and
difficulty concentrating. Marcus began therapeutic support
with this clinician at the NAHC in January 2003. His pre
senting issues included depression and adesire for "spiritual
and cultural growth." Marcus also stated that he "does not
want to return to self-destructive behaviors." The follow
ing is an exploration of his use of art therapy to maintain
balance of his ongoing substance abuse issues, pain man
agement, familial trauma through serious neglect and sexual
abuse, historical trauma-related issues, the ongoing physi
cal symptoms of HIV and medication-related side effects.
This case was chosen because it highlights the chronicity
of his ongoing struggles as well as the acute episodes of
emotional and physical pain that often accompany living
wllh HIVIAIDS. It serves as an illustration of art therapy
methods with the HIV-positive Native population. During
the course of his treatment at FCGC, this client received
art therapy in the clinic, therapeutic home visits, hospital
visits, and crisis intervention.
In Marcus's first session he created a sand tray en
titled "A New Beginning." Sand tray is a Jungian,
psychotherapeutic approach to working with symbols in
the psyche. "Symbols speak for the inner, energy-laden
pictures, of the innate potentials ofthe human being which,
when they are manifested, always influence the develop
ment of man. These symbols tell of an inner drive for
spiritual order" (Kalff 1980). Clients choose from a large
collection of archetypal figurines and arrange them in a 2 x
4 foot box of sand. They are then asked to talk about the tray
as a story. Personal and historical symbols emerge in the pro
cess ofcreating a sand tray and form a dynamic context for an
individual to make connections from the past to the present.
Mental representations ofthe emergence ofpersonal symbols
and stories can help clients to think in new ways about old
patterns. In his first sand tray Marcusrevealedhis innate sense
ofhope and desire to remain hopeful. He created an abundant
sand tray with many Native American figures representing
what he described as his desire to "return to the spiritual sup
port of his Native traditions" and find balance in managing
his ongoing mental health issues. This sand tray is a testi
mony to this man's ongoing belief and hope that he will be
okay. Despite the profound despair and hopelessness that sur
face through the course of his work in art therapy, Marcus
continues to believe in "A New Beginning."
FIGURE 1
Interlocking Mandalas
Art Therapy
In his second session Marcus was led into a medita
tion and asked to create a spontaneous drawing from the
meditation. Meditation and guided relaxation are indicated
for clients with high levels of stress and anxiety. A free
drawing made early in treatment serves as a baseline as
sessment tool to rule out glaring cognitive deficits, conduct
reality testing and provide diagnostic information regard
ing the client's connection with his inner world. This method
can be especially helpful in regard to cultural differences
in affect, use of spoken word and self-censorship that re
lates to levels of comfort in the therapeutic realms.
Ultimately, beginning weekly sessions with relaxation and
meditation techniques can increase a client's repertoire of
responses to the stress and anxiety of living with a life
threatening illness. Additionally, the meditation time
connects with the Native American belief in prayer as an
important aspect of healing.
In an early drawing (Figure 1 ) Marcus created inter
locking mandalas. Mandalas (circular drawings) are
fundamental symbols representing the infrastructure of
Native thought. The related medicine wheel is an impor
tant image in healing. The quadrants represent the four
directions and the four realms that Native Americans con
sider when looking at imbalances or emotional illness. The
mental, emotional, spiritual and physical realms of the in
dividual are seen as interrelated. Treatment of one realm
impacts all others. This representation of wholeness re
peated in Marcus's art images. Marcus reported that the
colors he used in creating his mandala are symbolic of " . . .
my emotional states: orange is my heart, blue is not feeling

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connected to my spirituality, black is my pain, red is my
emotions and purple is my intellect."
He emphasized black and red in the drawing, indicat
ing what was primary for him in this session. The orange
(symbolic of heart) is central on the page and it is clear that
Marcus has high levels of emotionality that make it diffi
cult for him to generate energy for other realms that are
important to him. From a family systems perspective, this
high level of emotion is related to reactivity to the original
emotional context. Marcus was often asked to think about
his current functioning in respect to his family system. "The
family is an 'emotional unit or system' and the symptoms
that show up in any individual are in fact related to the
emotional functioning ofthis unit or system" (Papero 1990).
The health of each family member may be directly related
to the functional state of the family unit. This is important
later as Marcus attempts to differentiate from his family
system, particularly his mother whom he both loves and is
ashamed of.
The client was then asked to amplify the strongest
pieces ofthe image and create a second drawing (Figure 2).
The image of Marcus's "pain" and "emotion" are literally
stomping on him. He represents himself in blue, the color
he associates with spirituality, and he is in a helpless posi
tion. The drawing clearly states what the client may not be
able to in words. His physical and emotional pains are liter
ally crushing him and, metaphorically, his spirit. This sense
of victimization and betrayal has deep roots in his family
system, as is revealed throughout his journey with art
therapy. This initial drawing session reflects his ongoing
struggle throughout the course of two years and continues
today. The client's ability to view the image with some ob
jectivity allows him to step out ofhis emotional enmeshment
and begin to think about how he will make the changes that
are necessary to his healing. He must stand upright and face
these entities that he has internalized, that torment him. In
terestingly, these intense images of helplessness and
victimization that emerge in the second session seem in
strong contrast to his initial images ofhope in his sand tray.
He has, in fact, internalized these polarities and is ambiva
lent about resolving them.
Marcus was asked to draw a family portrait in the next
session. He used stick figures to depict his family. They all
have happy faces, despite their known struggles and his
challenging relationship with them. Nothing conclusivecan
be determined from any one drawing, but how a client de
picts his family members and where he places them in
relation to himselfand to each other helps create a sense of
the dynamics within the system. The portrait can create a
starting point for discussion of family. It is important to
create a fluid dialogue through words and images that un
fold generational information about issues relevant to a
client's current situation and how he thinks about them.
In the next sessions, the client worked with profound
issues of shame in his family system, in particular his role
FIGURE 2
Pain and Emotion
/
Art Therapy
in absorbing his mother's shame. Marcus has a compli
cated relationship to his mother that stems from a long
history of inappropriate behavior on her part and her in
ability to manage healthy boundaries with herchildren and
her adult world. Her behavior varies within a pattern of
gross neglect and abuse due to her own addiction patterns
of severe dependency and helplessness. One of the ways
that Marcus has devised to manage this neglect and abuse
is to take ownership of his mother's behavior, in an at
tempt to regulate it within himself. This causes him deep
feelings of shame and discomfort but protects him from
being overwhelmed in addressing his anger and other in
tense feelings toward his mother. Figure 3 depicts Marcus's
attempt to acknowledge and separate from the inclement
weather of the "negative reinforcement" he experienced
as a child in his family. In the image, Marcus metaphori
cally removes himself from the "negative reinforcement"
and into the sunshine of "positive reinforcement." Though
Marcus's images can reveal his denial and simplistic an
swers, they also reveal clearly his pace, the obstacles he
faces and what he is willing to work on at any given mo
ment. The long history of sexual and emotional abuse inside
his home left him guarded, with poor ego defenses and
enmeshment issues. Marcus set the pace for his therapy by
creating images that were sometimes superficially bright
and optimistic with cheerful and simplistic answers. These
images allowed him to move slowly toward his understand
ing of how the pervasive sexual and physical abuse as well
as addiction patterns in the home he grew up in have ere-

Bien Art Therapy
FIGURE 3
Positive and Negative Reinforcement from Family
ated deep disturbances within him. It is difficult for Marcus
to reconcile these truths with his love and loyalty to his
family members, especially his mother.
The following image (Figure 4) depicts Marcus with
his partner of five years. He chose to switch gears and fo
cus on the present by drawing a current move with his
partner to a new house. Through denial, avoidance or any
number of defenses, the client decided to move away from
the overpowering feelings of shame and his visceral reac
tivity to them (later in the therapeutic relationship he could
not tolerate the repression ofthese feelings and the enmesh
ment with his mother and her shame resurfaced). For now,
Marcus works on what is current and less complicated. Fig
ure 4 has some of the stereotypical and superficial imagery
of previous images and speaks of what he wants to see at
this moment in his depiction of his house. As an art thera
pist, I look foraccess to the house. In this image the entrance
to the new house is obscure: the figures are too large for
the house and there is no doorknob to open the small red
door. In art therapy, houses are often thought about as sym
bols of the self. Marcus is telling me clearly how much
access to him he will allow. His drawing reiterates the pace
and boundaries thatmight not be expressed verbally. Bound
aries are incredibly important to trauma survivors, though
they may not always know how to create them. A drawing
with a house that cannot be entered could be a symbolic
request for safety. If there were no windows or doors at all,
the therapy would be at a different, perhaps more hopeless
place. There is access, but it requires patience and creativity.
In the next session, Marcus was depressed. His affect
was flat, his mood was down, and he stated that he had
some feelings of hopelessness. He said, "I have been in
therapy for five years and I thought I had gotten through a
lot of that stuff but it is right here." He believed that his 1 2-
Step substance abuse work was contributing to his mood.
Marcus's step-work required him to reflect on painful as
pects of his past. He was also dealing with feelings of
isolation within the group due to the controversial topic of
whether to use pain medications in sobriety (he takes pain
medications for neuropathy and other HIV-related pain).
Marcus had along history ofparticipation in 12-Step groups
in periods of sobriety and approaches the group with some
apprehension. At times he felt the therapy was more im
portant (and less complicated) than his participation in the
12-Step program. Briefly, 1 2-Step treatment strategies for
issues of addiction (such as Alcoholics Anonymous) are
grounded in Christian thought. Though some NativeAmeri
cans have found solace in Christianity, many have complex
and often unconscious reactivity to the messages at the heart
ofChristianity that conflict with indigenous thought. In art
therapy, Marcus talked about being "disloyal to family" and
worried that if he fully expressed his anger and pain it would
affect his loyalty to them. Marcus reported feeling "stuck."
He was asked to create a scribble drawing with his
nondominant hand. This is a technique that helps the client
discharge anxiety, connect with affective contentand think
differently about current dilemmas. Marcus created a blue
andred scribble (in previous drawings red represented emo
tions and blue stood for spirituality). In art therapy, images
and color symbology can have permanence-a client's use
of color or symbolic representation can be fixed over a pe
riod of time.

Bien Art Therapy
FIGURE 4
Changing Houses
This scribble exercise led to the next drawing, shown
here (Figure 5). This image reveals the client's continual
preoccupation with his mother and his unconscious deci
sions to carry family shame. A current incident involving
his mother and other family members reactivated his role
in the family-to carry the shame for the family's inappro
priate behavior. The drawing contains two images separated
by a line down the middle. On the left is the family shame
hanging over an image of himself. This is similar to previ
ous imagery ofhaving his family's "negativereinforcement"
hanging over him. On the right, the client has drawn his
mother and the shame that surrounds her. Issues ofenmesh
ment are paramount in this client. Many of his efforts in
therapy revolve around family enmeshment and attempts
to differentiate from them, and the cost of having a sepa
rate self.
He continued processing his shame by creating a sand
tray in the next session entitled, "Fear." In this tray Marcus
chose figures to represent his own shame and judgement.
They were large and ominous figures placed defiantly in
the sand. He confronted these entities and began to move
them in the tray. In the dynamic process that followed,
Marcus overpowered these entities and rather than annihi
lating them, transformed them. He abdicated his
responsibilities to carry his mother's shame and created a
different story in the tray. He titled the new tray, "Freedom
from Bondage." In this new tray/story his shame was re
named "humility" and judgment was transformed into
"trusting the self." This may appear a superficial response
to deeply rooted feelings of shame and judgment in his
family history, but it gave the client the ability to perceive
himself as the creator of change. His thought processes
cleared as he distanced himself from the intense and de
bilitating emotional reactivity to his mother's "shameful"
behavior. Over the next few weeks Marcus continued to
explore the lineage of shame in both sides of his family
and was able to think differently about his relationship to
carrying this shame.
Over the next month, Marcus had a stressful visit from
his mother, which contributed to his alcohol relapse and
admission to a detox center. During his mother's visit
Marcus became extremely depressed and physically ill,
with high fevers, excessive vomiting and intense neuro
pathic pain. While she was visiting and the client was
bedridden and very ill, he was reminded of a previous in
cident at his mother's home. Marcus stated, "In 1997, I
was sent home by my doctors to die." He had only a few T
cells, PCP (Pneumocystis carinii pneumonia) and at that
time was not responding to available medications. Marcus
reports that "I was dying on my mother's couch and she
would not take me to the hospital because she was waiting
for a phone call from her husband." He reports that, ulti
mately, he was taken to the hospital by a friend and was
put on the first protease inhibitors. Marcus believes that
had his friend not taken him to the hospital he would "have
died on her couch" and she "would have done nothing."

Bien Art Therapy
FIGURE S
Shame
Marcus's devastation at his mother's inability to act on his
behalf was triggered by her current visit, where he was hav
ing an exacerbation of symptoms as he was bed-ridden.
His mother was unable to comfort or nurture him.
Recounting this memory was painful for Marcus, but
ultimately instrumental in his ongoing work withinthe fam
ily system and a deeper understanding of his role in the
family system and its effects on his emotional and physical
health. But he continued to have difficulty understanding
that his decline in physical and mental health and subse
quent relapse may have been a result of his mother's visit
and the complicated and opposing feelings he has toward
her. During the following months, he regained sobriety, sta
bilized his medical condition and began to address the
conflicts in his current relationship to his partner. Marcus
continued his work in weekly art therapy.
A month after his hospitalization, Marcus drew a new
piece, returning to the familiar image of the mandala. In it,
he depicted himself surrounded by medications. There is a
black circle by the two mandalas in the image, which he
described as "old ambivalence." He also depicted a mandala
with hopeful images that he called "new peace." The con
tinual theme of "new and peaceful self' juxtaposed with
all that is old, painful and familiar is present here.
Two months later, Marcus worked on a dream in his
session by drawing it. Describing the drawing, Marcus
stated: "This is me reaching up to the heavens for support.
The black is a gate opening to let the dead through who are
reaching up to try and get me. My dream is really about
living. The red is the life force. The green hand is peace
and the red is me away from the world of the dead." Marcus
used it to represent him and the life force itself. This image
continues to reiterate fundamental life polarities within: life
versus death, sanity versus madness, Native versus non
Native, sickness versus health, generational information
versus present day attempts to differentiate. Marcus entitled
this image, "Peace, Balance, with Inner Struggle."
After another two months, Marcus created a drawing
entitled, "Happy Days are Here Again"(Figure 6). In the
session, his mood was angry and his affect was flat. His
speech was slurred and he appeared to be overmedicated.
He reported, "Every time I leave the doctors office, I have
a new prescription. I am afraid of all these psych meds."
His mood and thoughts were incongruent with the title of
his piece. The imagery attempts to create a happy scene,
but, the figures and tree appear to be slipping toward the
ravine in the middle of the hills. The faces on the figures
are smiling, but they do not appear stable. Marcus contin
ued to want to perceive his life as on the upswing, and this
image may have been a last ditch effort to keep him from
sliding into the ravines of his life.
He was unsuccessful in staving offthe depression and
in the next session reported feeling hopeless. He was strug
gling with physical and emotional pain and stated that it
was impossible to separate them. Marcus attempted to work
on a photo essay project to stabilize his mood. However,
his depression became entwined with his physical symp
toms of pain, vomiting, fever, and sleep disturbances. His
thought processes were affected and ultimately Marcus be
came suicidal, with intent and plan to harm himself and
was taken, against his will, to a psychiatric unit. After the
incident, he stated that he was angry with his partner and

Bien Art Therapy
FIGURE 6
Happy Days?
this clinician for intervening, and experienced the event as
retraumatizing. When Marcus was discharged from the psy
chiatric unit he became ambivalent about therapy. He
reported feeling betrayed and traumatized by his experi
ence. But Marcus did eventually return to therapy, and
reported, "I realize that I need to go deeper into therapy. It
is my past that is really haunting me." Figure 7 is Marcus's
attempt to process the traumatic experience of being re
strained and taken to a psychiatric unit. This image focuses
on the helplessness and victimization ofthe event and deep
pain, anger and loneliness that Marcus has felt throughout
his life. In creating this image as raw and uncensored,
Marcus was able to express himself fully, before beginning
to think about the event as a culmination of his traumatic
past. In the following sessions, Marcus was able to think
about his role in the event and shift his identity as victim,
increasing his sense ofmastery and competence in manag
ing his anxiety, depression, and feelings of hopelessness.
Marcus considered the possibility that his ability to stabi
lize into a state of balance may be related to the lack of
emotional stability in his family of origin and his percep
tion that his well being might be interpreted as disloyalty to
the family system.
The final image (Figure 8) explores a dream. Marcus
had stabilized from his recent hospitalization, though his
affect was tearful and he continued to have sleep problems.
He reported having some social phobia and anxiety "get
ting out the door." He reported feeling motivated to
"understand what I am experiencing." In Marcus's dream,
/-1.-1"1"/ P..,� <1'<(.. 1-......
-':;l··�
he met a biological twin and made love with him. The
dream can be seen from many perspectives. It could indi
cate Marcus's attempts to integrate a fragmented piece of
the self. Marcus can metaphorically "love" himself and
make peace with the separateness and loneliness that he
often experiences. Marcus could also be trying to confront,
and perhaps normalize, the traumatic sexual abuse he en
dured as a child and the severe neglect by his parents.
Culturally, twins can represent elements ofancient cre
ation stories. In one Dine creation story, a twin is named
"the Monster Slayer." Perhaps Marcus, in his dream state,
empowered the self to slay the many monsters he must
continually face. I asked Marcus to research how twin
dreams were perceived from his own Cherokee tradition.
Most important is Marcus's own interpretation of this
dream, and the messages, symbols and metaphors he reads
in his dream world. Marcus gathered information from the
elders in his community. They told him:
The dream of self in the form of twins depicts two pictures
of oneself. There is the evil self: Envy, anger, sorrow, regret,
greed, arrogance, self-pity, guilt, resentment, inferiority,
lies, false pride, superiority and ego . . . . Then there is the
good self image that sees joy, peace, harmony, love, hope,
serenity, humility, kindness, benevolence, empathy, gener
osity, truth, compassion and faith . . . To see them join and
become one is to see oneself become whole, to embrace all
parts of self and then to decide how to hold these two pieces
together without letting one rule or dominate the other, al
lowing them to live together in harmony without rehashing

Bien
Art Therapy
FIGURE 7
Processing Trauma
internal war again. Each part plays a significant role in al
lowing me to be complete. All feelings, needs, desires
should be fed to remain healthy but a balance must be found
within to live out my life as a person that has all feelings,
needs and desires without dominion over the other opposite
side.
Marcus's uncle told him, "Dreams of this nature are said in
usual circumstance to be played out by animal guides. The
two parts almost always played as one form, i.e., two
wolves, two bears, two mountain lions; but when it comes
in the form of the true self the person is believed to be in
touch with all realms of their existence, meaning the emo
tional, mental, physical and spiritual planes are all being
touched and played upon as pawns in a game pitting one
against the other and only allowing each piece ofthe puzzle
to be seen separately and almost never all in one place at
one time."
Marcus's continued use of art therapy helped to eluci
date the powerful ambivalence he has concerning wellness
and balance. Images are not products of the intellect and
through them Marcus could see what his mind had a hard
time believing. The history of substance abuse and various
forms of neglect on both sides ofhis family was very strong,
and sobriety and well being often became a tangled sym
bol for disloyalty. It is doubtful that he could have seen
these internal dilemmas without the use of a more primal
communication method. Currently, Marcus is soberand has
maintained sobriety since his last relapse over a year ago.
He continues tojuggle the medical issues inherent in AIDS,
the insidious effects of trauma (collective and individual),
and gain spiritual support from his Native community. He
also is determined to find ways to express his pain around
his past as well as remain in contact with family.
CONCLUSION
"Whenever illness is associated with loss of soul, the
arts emerge spontaneously as remedies, soul medicine"
(McNiff 1992).
Native Americans make up a small percentage of the
general population in the San Francisco Bay Area. Still,
when an epidemic strikes a small population the results are
devastating, compounding the already painful effects of
genocide and historical trauma. In working with the Na
tive American population, existing therapeutic paradigms
sometimes fell short and seemed culturally inappropriate.
The FCGC's commitment to providing culturally compe
tent services has led to innovative, creative strategies that
have benefited HIV+ NativeAmericans living in San Fran
cisco. Understanding complex generational issues and the
physiological and developmental effects of trauma have
been key to supporting Native community members. As
examined in the case illustration presented, trauma can re
sult in the loss of soul or spirit. This loss can manifest in

Bien Art Therapy
FIGURE S
Marcus' Dream
cycles of substance abuse, ongoing mental health distur
bances, and issues of identity and connectedness. The
process of making art brings attention to this loss of spirit,
and awakens an innate desire to create and make sense of
personal images and symbols. Art therapy attempts to re
store balance to the self, which in turn can bring balance to
the greater community.
As this article was in the last editing stages Marcus,
unexpectedly, passed away. The news came as a greatshock.
Marcus had never seemed stronger. His life had finally
reached a moment of peace and stability. His spirit was
strong. It is difficult to understand after all that he has en
dured . . . why now? He will be greatly missed by the
community who he loved and needed and who loved
and needed him. I am grateful for all he taught me along
the way.
REFERENCES
Brave Heart, M.Y.H. 2003. The historical trauma response among natives
and its relationship with substance abuse: A Lakota illustration.
Journal ofPsychoactive Drugs 35 ( I ): 7-1 3 .
Bussard, A. & Kleinman, S. 1 99 1 . A rt therapy with AIDS patients. In:
H.B. Landgarten & D. Lubbers (Eds.) Adult Art Psychotherapy:
Issues and Applications. New York: Brunner-Routledge.
Chapman, L.; Morabito, D.; Ladakakos, D.; Schrier, H. & Knudson, M.
200I . Theeffectiveness ofart therapy interventions in reducing post
traumatic stress disorder (PTSD) symptoms in pediatric trauma
patients. Art Therapy: Journal of the American Art Therapy
Association 1 8 (2): 1 00-04.
Herman, J. 1 992. Trauma and Recovery. New York: Basic Books.
Jim, N. 2004. The morning god comes dancing: Culturally competent
mental health and HIV services. In: E. Nebelkopf & M. Phillips
(Eds.) Healing andMental Healthfor NativeAmericans: Speaking
in Red. Walnut Creek, California: AltaMira Press.
Kalff, D. 1 980. SandPlay: A PsychotherapeuticApproach to the Psyche.
Boston, Massachusetts: Sigo Press.
McNiff, S. 1 992. ArtAs Medicine: Creating a Therapy ofthe Imagination.
Boston: Shambhala Publications.
Papero, D. V. 1 990. Bowen Family Systems Therapy. Boston :
Massachusetts: Allyn and Bacon.
Spring, D. 1 993. Shattered Images: Phenomenological Language of
Sexual Trauma. Chicago: Magnolia Street Publishers.
Vernon, J.S. 200 1 . Killing Us Quietly. Lincoln, Nebraska: University of
Nebraska Press.

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