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Section 15
Utilizing Drawing in Play Therapy

Question 15 | Test | Table of Contents

Drawing
For children, drawing is usually an enjoyable art activity in which paper and pen (or pencil, crayon, and magic marker) are used to create shapes and symbols, explore the connectedness of parts to the whole, and give visible form to feelings and ideas. Most children draw symbolic pictures that replace words, but still convey meaning and affect within the therapeutic relationship (Burns, 1970; LeVieux, 1994; Nickerson, 1973, 1983). Thus, drawing can be a purposive and fairly direct representational method for understanding the conflicts and issues that trouble a child client (DiLeo, 1970; Kramer, 1971; Loewald, 1987). For example, a child may select astronauts to symbolize conquering the unknown or fleeing a difficult situation, soldier or knight figures to represent conflict and aggression or rescue efforts (Reeves and Boyett, 1983).

While each drawing is individually configured and unique in meaning, common pictorial symbols and metaphors of human figures and animals, place and weather, and toys and games usually convey fairly general meanings-albeit at times with wide variance from one culture to another (Oster and Gould, 1987). For example, alligators and other big mouth animals may be used to reflect nurturant needs or oral aggression; dogs and other cuddly animals, companionship and transitional objects; or birds, flight and freedom. Caves may hide and protect or, conversely, trap. Mountains may be attainments, obstacles, or something else entirely. Rain may reflect crying or be cleansing. Snow seems cold, the sun warm. How then, with these and the myriads of other possible meanings, does the clinical social worker figure out what a particular child has in mind? In part, the answer lies in asking the child directly (Timberlake, 1978a; Webb, 1991). In addition, the representational ways in which individual children condense multiple metaphors, details, and memories into one picture and their action style in doing so provide indirect clues to the more individualized meaning in their drawings. To make educated decisions about which of these polar opposite or nuanced generic meanings most accurately represents a nonverbal child's intended meaning, clinicians draw on their understanding of this child gained during psychosocial assessment and other interviews, comment on the observable, and await the child's own nonverbal or verbal confirmation that the observation is accurate or not.

The Birds and the Bees
Althea G., age eight, was referred to the mental health clinic by her pediatrician for failure to attend school, fear of leaving home, anxiety about failing to perform adequately, nightmares, and morning nausea unrelated to physical illness. Her symptoms had worsened over the last two years. Two years ago, her maternal grandmother died. Her sister also entered school about this time. Biopsychosocial assessment revealed Mrs. G.'s depression, Mr. and Mrs. G.'s marital conflict, and Althea's school-phobic anxiety. Mrs. C. entered treatment for depression. Mr. and Mrs. C. were seen together biweekly for marital counseling and parental guidance work. Althea began play therapy and immediately expressed her concerns and issues through drawing. In her first drawing (Figure 3.1), Althea expressed her fears and anxiety about therapy by drawing herself in a window placed between two empty windows and guarded by a witch. She drew borders on her early pictures to contain her anxiety and avoid spill over The remaining figures illustrate the ongoing metaphors and process themes throughout her year of treatment. Figure 3.2 is representative of early drawings of her feared school - a dark building that has bars on the door and windows and is located in a dreary environment. Figure 3.3 picks up on her concerns and fears about leaving her parents and conveys a sense of self caught between two parent teepees and roasted over fiery feelings.

Figures 3.4, 3.5, and 3.7 pick up a recurring sexual theme of the birds and bees. This theme surfaced as the clinical social worker began dealing with the parents' marital problems and working with them to move Althea out of the marital bed and back to her own room. This six-month-long theme slowly shifted as Althea became increasingly comfortable with her parents' realignment in their couple and parental roles. In Figure 3.7, for example, the bees are loudly communicating.

Figure 3.6 (about two thirds of the way through treatment and in the midst of the recurring birds and bees sexual narrative) is a graphic representation of Althea's reaction to the clinical social worker's vacation-the wicked witch flies away leaving the scared ghost to deal with the fearful house alone. Figures 3.8 and 3.9 represent Althea's self-portraits at termination, presenting quite a marked contrast to her initial portrayal of self and a definite lessening of the heavily constricted boundaries surrounding her earlier picture.

Therapeutic use of drawing is based on the assumption that child clients project their perceptions, feelings, conflicts, and developmental disturbances into their pictures. A note of caution is in order, however, as children's drawings are also influenced by (1) techniques and symbols taught in school; (2) symbols and metaphors familiar in their familial and cultural environments (Sutton-Smith, 1986); (3) psychosocial developmental stage, visual perceptual ability, and motor-muscular coordination; and (4) availability of particular drawing tools, colors, and paper.

The symbolic representations in their drawings offer child clients a sense of control over the external and internal forces depicted. The process of drawing provides opportunity for them to relive their experiences in an active role, even though the original role may have been passive or overwhelming. While integrative and healing properties are present in this creative process, it is important to note that the cathartic effect alone is not sufficient for lasting change (Barlow, Landreth, and Strother, 1985). For change to occur, the clinical social worker searches for the additional clues about children's conflicts, problems, and distortions of reality that are found in the drawings and related narratives. By following the child's therapeutic process, the clinician is able to encourage further exploration and comprehension, not only of the content being expressed in a picture or picture series, but also of the underlying developmental and conflictual themes. For example, child clients provide the key to their own unique symbolic logic, mental processes, and core conflictual themes through their picture content, distortions and emphases, inclusions and omissions, drawing style, and accompanying narrative. In using this play activity, it is easy to see that the clinician may either work within the metaphor and interpret only in terms of the picture itself or encourage verbalized self-observation, autobiographical narrative, reflection, and insight as part of the therapeutic process. Thus, through their drawings, children are helped to observe, interpret, and communicate their understanding of themselves and their world, their attitudes and affects, their issues and conflicts, their strengths and vulnerabilities.
- Timberlake, Elizabeth & Marika Cutler, Developmental Play Therapy in Clinical Social Work, Allyn & Bacon, Needham Heights: 2001.

Personal Reflection Exercise Explanation
The Goal of this Home Study Course is to create a learning experience that enhances your clinical skills. We encourage you to discuss the Personal Reflection Journaling Activities, found at the end of each Section, with your colleagues. Thus, you are provided with an opportunity for a Group Discussion experience. Case Study examples might include: family background, socio-economic status, education, occupation, social/emotional issues, legal/financial issues, death/dying/health, home management, parenting, etc. as you deem appropriate. A Case Study is to be approximately 250 words in length. However, since the content of these “Personal Reflection” Journaling Exercises is intended for your future reference, they may contain confidential information and are to be applied as a “work in progress.” You will not be required to provide us with these Journaling Activities.

Personal Reflection Exercise #1
The preceding section contained information about utilizing drawing in play therapy. Write three case study examples regarding how you might use the content of this section in your practice.
Reviewed 2023

Update
Art Interventions for Children With Autism Spectrum Disorder: A Scoping Review

- Rennie, C., Irvine, D. S., Huang, E., & Huang, J. (2022). Music Therapy as a Form of N Bernier, A., Ratcliff, K., Hilton, C., Fingerhut, P., & Li, C. Y. (2022). Art Interventions for Children With Autism Spectrum Disorder: A Scoping Review. The American journal of occupational therapy : official publication of the American Occupational Therapy Association, 76(5), 7605205030. https://doi.org/10.5014/ajot.2022.049320

Peer-Reviewed Journal Article References:
D'Souza, A. A., & Wiseheart, M. (2018). Cognitive effects of music and dance training in children. Archives of Scientific Psychology, 6(1), 178–192. 

Gavin, S., Meany-Walen, K. K., Murray, M., Christians, A., Barrett, M., & Kottman, T. (2020). Play therapists’ attitudes toward using technology in the playroom. International Journal of Play Therapy, 29(1), 1–8.

Goicoechea, J., & Fitzpatrick, T. (2019). To know or not to know: Empathic use of client background information in child-centered play therapy. International Journal of Play Therapy, 28(1), 22–33. 

QUESTION 15
The therapeutic use of a drawing is based on what assumption? To select and enter your answer go to Test.