Art Therapy With Puppet Making To Promote PDF
Art Therapy With Puppet Making To Promote PDF
Art Therapy With Puppet Making To Promote PDF
Bani Malhotra
To cite this article: Bani Malhotra (2019): Art Therapy With Puppet Making to Promote Emotional
Empathy for an Adolescent With Autism, Art Therapy, DOI: 10.1080/07421656.2019.1645500
Article views: 29
Bani Malhotra
development. The use of art materials with visual and Shapiro, 1975). Using puppets with clients with ASD
tactile diversity facilitates sensory modulation, emotional promotes empathetic responding and self-awareness
regulation, flexibility, and attachment with ASD individ- (Emery, 2004; Schrandt, Townsend, & Poulson, 2009),
uals (Durrani, 2014; Schweizer, Knorth, & Spreen, as well as communication (Trimingham, 2010). Based
2014). Isserow (2008) suggested implications for art on the aforementioned literature, this in-depth case
therapy in developing joint attention through shared tri- study aimed to describe how puppetry in art therapy
adic relation of the image, client, and therapist as a could enhance emotional empathy for a child with ASD.
foundation to construction of affective and cognitive per-
spective taking. Martin (2009b) and Allen (2009)
asserted that artwork can serve a function of an object
that children and adolescents can refer back to over Case Design
time, in the form of a coping strategy.
Client
Expressive Therapies Continuum
Lisa (pseudonym) was a 16-year-old African-
The Expressive Therapies Continuum (ETC) was American female diagnosed with ASD who received edu-
developed by Kagin and Lusebrink (1978) as a schematic cation and therapeutic services from a nonpublic special
framework for visual expression based on three levels of education day school in an urban area. Autism preva-
information processing. The three levels are kinesthetic/ lence studies differ across gender and racial or ethnic
sensory (K/S), perceptual/affective (P/A), and cognitive/ groups, indicating a lower prevalence or underreporting
symbolic (C/Sy), and a creative level that can apply of autism in African Americans (Mandell, Ittenbach,
through any or all of these (Kagin & Lusebrink, 1978). Levy, & Pinto-Martin, 2007). I worked with Lisa as an
According to Lusebrink (2010), the kinesthetic, percep- art therapy intern and had been working with her for
tual, and cognitive components of the ETC could be 4 months prior to implementing puppet making. Lisa
enhanced through the use of resistive materials (pencils, previously received art therapy from my site supervisor
crayons, or markers), whereas fluid media (watercolor, for 6 years. I secured informed consent from the client’s
paints) could be used to enhance sensory, affective, and parents and assent from her.
symbolic aspects of information processing. The overall
choice of art material could improve other weaker levels
of ETC. In describing the best practices for art therapy
with ASD, Van Lith, Stallings, and Harris (2017) high- Measures
lighted the use of ETC to reflect the use of art materials Face Stimulus Assessment. The Face Stimulus
with therapeutic aims. The authors suggested a “top-
Assessment (FSA) is an art therapy assessment designed
down” approach starting with materials at the cognitive/
for individuals who have communication difficulties
symbolic level to encourage relationship building with
(Betts, 2003, 2016). The FSA includes a series of three
the client and addressing goals related to cognitive
images (depicting a complete face stimulus, an outline,
growth and then moving toward a gradual transition to
introduce more sensory and kinesthetic fluid materials. and blank paper) designed to reveal the client’s capacity
for memory and visual retention. The FSA provides
graphic equivalents of diagnostic criteria for autism
Puppetry in Therapy
through a modified version of the Formal Elements Art
Puppetry has been used as a valuable medium in Therapy Scale (FEATS; Betts, 2013; Gantt & Tabone,
therapy (Bernier & O’Hare, 2005) and psychotherapy 1998). Its reliability and validity for FSA has been estab-
(play therapy, art therapy, drama therapy) to express dif- lished for a population with attention deficit/hyperactiv-
ficult feelings and engage in conflict resolution (Bender ity disorder in South Korea (Kim et al., 2014).
& Woltmann, 1936; Jenkins & Beckh, 1942). Cassell
(1965) wrote that children are more easily able to
express their feelings through a puppet because it enables Interpersonal Reactivity Index. EE was assessed
children to release feelings that they are unable or using the IRI (Davis, 1983), which is a self-report meas-
unwilling to express directly. Puppets in therapy have ure used with ASD individuals in previous literature.
been regarded as an extension of self or the environment The IRI includes 28 items on a 5-point Likert scale
and range from simple to complex types of puppets ranging from does not describe me well to describes me
including paper bag hand puppets, finger puppets, and very well. The measure has four subscales—perspective
marionettes (Bernier, 1983). Puppetry in art therapy taking, fantasy, empathic concern (EC), and personal
involves puppet making for use in play designed to meet distress—of which EC is the measure of EE. The IRI
specific therapeutic goals (Bernier, 1983; Gerity, 1999). was originally validated on college student populations
Puppetry has also been widely used in therapy as a diag- and since, has been widely used across populations in
nostic tool (Howells & Townsend, 1954; Irwin & several languages (Konrath, 2013).
MALHOTRA 3
Session Plan provide further structure to the session, every other week
Lisa chose one feeling to explore from the following cat-
The puppetry intervention consisted of 12 30-min egories: sad/loneliness/grief, happy/calm/excited, and
art therapy sessions over the course of 3 months. These anxious/nervous/worried. These feelings were grouped as
sessions were incorporated into Lisa’s regular art therapy such because Lisa often used them interchangeably. Her
treatment as usual and were based on her Individualized selection also offered an opportunity to assess if Lisa
Education Program (IEP) goals toward emotional regula- would choose different emotions from one style of pup-
tion and socialization. I developed the structure and con- pet making to another, and from puppet making to pup-
tents of the sessions based on previous literature, pet play.
experience working with the participant, and suggestions I wrote process and progress notes following each
from my supervisor. session that included behavioral observations, client ver-
I employed three distinct styles of puppet making. balizations, and photographs of the client artwork and
The puppet tasks ranged from simple to more complex puppets. This process ensured accurate reporting, reflex-
types (Bernier, 1983), thereby using the ETC model ivity, and identifying connections to art therapy theory
with a goal of engaging materials that could facilitate and the ETC.
cognitive to sensory/kinesthetic interaction. I made three
samples of each type of puppet to offer Lisa more
choices and encourage originality (Figure 1). Each of Summary of Art Therapy Sessions
these samples displayed facial features to correspond to
uniform emotions: happy girl, sad boy, and neutral elder Lisa used different media to explore different emo-
man. I created one as an older man because Lisa missed tions during the puppet making and puppet play
several older male teachers and her older brother. (Figures 2 and 3). Table 1 presents a brief summary of
I explained the workings of each puppet, modeled the 12 sessions indicating the task, emotion explored,
movements and tone, and allowed Lisa as much time as and media used. The sessions were notable for four over-
needed. Each puppet making was followed by client- arching themes: (a) interpersonal interactions, (b) intra-
directed unstructured puppet play to encourage spontan- personal processes, (c) awareness of others’ emotions,
eity. Bernier (2005) stated that client-directed puppet and (d) externalization.
play involves the client taking on the role of script
writer, actor and puppeteer, and director, and engages Interpersonal Interactions
the therapist by taking on roles according to the client’s
direction. During sessions when she did not want to cre- Lisa used art therapy sessions to explore both posi-
ate or play with puppets, I encouraged Lisa to create a tive and negative interpersonal interactions. She
self-portrait focused on facial expressions and emotions described her positive interactions with previous male
to maintain focus on self-awareness. At the beginning teachers (“He’s fashionable, telling jokes”) and negative
and end of the 12-week puppet making and puppet interactions with one of her classmates (“Stay away from
play, I administered a pre- and post-FSA and IRI. To [student], don’t have to talk to her”). She displayed a
4 ART THERAPY WITH PUPPET MAKING
Externalization
as her schema remained the same. However, the color fit Implications
and details on the eyebrows improved in the post-FSA.
The pre- and post-IRI scores indicated an increase in the Including puppets in art therapy served as a catalyst
EC scale and no notable change in the other three scales for encouraging interpersonal and intrapersonal interac-
(Table 2). tions, awareness of others’ emotions, and externalizing
of feelings for the participant, all of which are crucial
processes in developing emotional empathy. The art
therapy assessment and the self-report empathy measure
provided insights on the direct changes noted in
her responses.
The puppets functioned as a safe and somewhat
controllable physical object for exploration of complex
feelings. The use of puppets served as a medium to
externalize Lisa’s feelings of loneliness and anxiety.
Trimingham (2010) proposed a similar process in pup-
petry with autism: “children are confronted with an
externalization of themselves, a sudden focus away from
their closed inner world, as if another presence suddenly
shares their lonely perception of the world” (p. 256).
Lisa explored emotional conflict and confusing experien-
ces through puppet play, thereby using puppetry in
improvising to engage in problem solving through the
process of doing it, and not merely imposing a rational change in Lisa’s EC scale suggests a change based on
outcome (Bernier, 1983; Trimingham, 2010). Lisa also the art therapy intervention. This use of the IRI as a
used the puppets in mirroring movements and facial pre–post measure raises questions of EE as a state or trait
expressions of the therapist and then independently used measure. Considering the change in EC measure, I sus-
hand gestures to express feelings through the puppet. pect that EE could be a state-based measure dependent
This can be correlated with increased social interaction on the empathetic response to others’ expressive behavior
and self-awareness in motor empathy (Hildebrandt et al., (Nezlek, Schutz, Lopes, & Smith, 2007). Krahn and
2016). Puppets have been regarded as transitional objects Fenton (2009) reported that for a response to count as
linking the inner and the outer worlds. Lisa would con- empathetic, it must be informed by an understanding of
stantly bring up attachment to her brother and old both oneself and another. This study shows evidence in
teachers in puppet play, thereby using puppets as a the qualitative data with interpersonal and intrapersonal
“bridging” space or an extension or representation of the themes that emerged for Lisa as a result of art therapy.
self or aspects of others in the environment (Bernier, Smith (2006, 2009), in proposing CEDD to be a part
2005). The puppet also functioned as a transferable cop- of autism, explained that even though people with aut-
ing skill, an object added to Lisa’s “coping bag” that she ism might share others’ emotions, they might be unsure
could remember and refer to in the future. about its source or how to manage it, making it a strug-
Although previous literature suggests different forms gle for ASD people to step back from the overwhelming
of inclusion of puppets in therapy (finger puppets, hand empathic connections resulting in an empathic imbal-
puppets, marionettes, shadow puppets), virtually nothing ance. This case study also indicated that Lisa often exter-
could be found on the role of the ETC (Kagin & nalized her own emotions on others, not clearly
Lusebrink, 1978) in puppet making. A range of art distinguishing theirs from hers.
materials were offered to Lisa for puppet making. Lisa An in-depth exploratory case study details provides
started the first puppet using only resistive materials, directions for further research for incorporating puppets
such as markers, which generally activate the left-hand in art therapy when working with clients with ASD.
components of ETC: kinesthetic, perceptual, and cogni- Even though I observed that Lisa incorporated the pup-
tive. The rainbow schema, destruction of material (thin- pets as a coping strategy, it would be crucial to follow
ning of paper bag with excessive coloring) and up the extent of usage of puppets and its continued
predominance of outlines with rigid structure, support influence on EE. A limitation of the IRI scale as a verbal
the psychopathological variation in Lisa’s visual expres- measure was noted as some of the questions were beyond
sion (Lusebrink, 2010). In subsequent sessions, Lisa used Lisa’ s comprehension. Future investigation warrants
various fluid mediums and textures including paints, inclusion of a more appropriate EE measure suited for
yarn, felt cloth, and paint sticks, engaging the sensory individuals with ASD. Considering the versatility of the
and affective levels of ETC. The structure of simple to nature of puppets and previous literature on the effect of
complex puppet forms (bag, finger, sock) might have movement on EE, further study on embodiment using
mobilized exploration on different levels of the ETC puppetry with ASD would be crucial in investigating
during the course of the intervention. EE. This case focused on the puppets’ facial expressions.
The FSA results correspond to many of the graphic Effects of a broad range of puppets with full body with
equivalents of Diagnostic and Statistical Manual of movements could shed further light on their usefulness.
Mental Disorders diagnostic criteria for ASD (Betts, It will be worthwhile to consider neuroimaging and psy-
2013). Lisa’s graphic developmental level matches the chophysiological techniques as an objective measure for
quality of drawings by latency-age children with more EE pathways, especially with the ETC approach.
detail for individual features. This corresponds to her
significant global cognitive deficits in comparison to
same-age peers conforming to the diagnostic criteria of Conclusion
impairment in social interaction and communication.
The FSA has direct implications on measurement of cog- Overall, this case study supports the use of puppets
nitive capacities (memory and cognitive flexibility) for in art therapy as symbolic of a surrogate therapist
CE as noted in the literature (Davis, 1994). Lisa also (Brown, 2005) or the art therapist’s third hand (Kramer,
displayed schema stalemate, drawing the same schema of 1986). This reciprocal and reflexive interrelationship of
human face with little or no changes in the self-portrait the art or puppet, therapist, and the client facilitated
(Martin, 2008). Lisa’s ability to process situations and scenarios. These
The findings from the IRI (Davis, 1983) on the EC interactions helped her brainstorm solutions for coping
scale indicate a remarkable increase from the pre- to with difficult emotions for the puppet and in turn for
post-self-report measure. The preassessment of the EC herself. This protocol provides insight into the know-
subscale for Lisa was notably lower than the perspective ledge and understanding of art therapy as a treatment
taking subscale. This conforms to the experimental evi- for adolescents with autism, and therapeutic puppetry as
dence suggesting a significantly low score on the EC a nonconfrontational tool for socioemotional and behav-
scale of the IRI (Trimmer et al., 2017). A consequential ioral development leading toward EE.
8 ART THERAPY WITH PUPPET MAKING
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