I am pursuing my Master’s in Art Therapy currently and am learning about child and adolescent development in one of my classes. This is one of my essays, which I am happy to share received an A. My passion for these topics is unmatched and I strongly believe that therapists with lived experience are an asset to the field.

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Introduction

Bipolar disorder is a mental illness recognized by the DSM that has an onset age in the teenage years or early 20s. Bipolar disorder is “a brain disorder that causes unusual shifts in mood and energy…Symptoms of bipolar disorder are severe. They are different from the normal ups and downs that everyone goes through from time to time. They can result in damaged relationships, poor school performance, and even suicide” (“Bipolar disorder in children and teens,” pg. 1). In addition to this, bipolar disorder has overlapping characteristics and symptoms as other diagnoses such as depression, anxiety, borderline personality disorder (BPD), premenstrual dysphoric disorder (PMDD), and attention-deficit/hyperactivity disorder (ADHD). Due to this, it can be difficult to formally diagnose bipolar disorder in children. The hallmark characteristics of bipolar disorder include manic episodes, which can consist of high energy and irritability, depressive episodes where sadness and hopelessness are prevalent, and mixed episodes, which portray mania and depression simultaneously. In children, there are many stressors faced during their development such as puberty, new school environments, and peer pressures. In addition to these everyday challenges, some children also face discrimination due to their culture, race, sexual orientation, weight, and more. It is a true challenge to know what is the root cause of one’s mental distress when some children face unfair circumstances and others hold great privilege or have advantages when compared to their peers. Due to the nature of bipolar disorder, it can be difficult to diagnose and treat, especially if the caregivers are wary of their child taking prescribed medication or paying for therapy sessions. There are also concerns within some family units of access to health care or stigma remaining prevalent. With the support of loved ones, access to health care, and a professional support network, as well as an acknowledgment of the disadvantages and challenges each child systemically faces, children facing bipolar disorder can thrive. 

One study in particular found that “depressive episodes are more prolonged in patients with anxiety co-morbidity, both at the level of anxiety symptoms or syndromes (Coryell et al. 1992, 2009). In addition to this, “Co-occurrence of an anxiety disorder also increases the risk of suicide attempts in people with major depressive disorder (MDD) or bipolar disorder (BP) (Sareen et al. 2005). Moreover, BP with co-morbid anxiety can pose a significant therapeutic quandary since antidepressants, the treatment of choice for most anxiety disorders, may be problematic in patients with BP, particularly those with rapid cycling (Goes, pg. 1). Learning that bipolar disorder has high co-morbidity with an anxiety disorder or MDD lends to the fact that immense caution must be taken when diagnosing clients. Due to the immense overlap in symptoms, it is recommended that a perspective of a differential diagnosis be taken, which is where it is psychologically recognized multiple other diagnoses may overlap and the behaviors are monitored to ensure the appropriate diagnosis and treatments as the child grows up.

Rationale

I chose the topic of using art therapy interventions with children with bipolar disorder because I was diagnosed with bipolar disorder in 2019. It took experiencing a second severe episode of psychosis to finally be properly diagnosed. It was known as a teenager that I was struggling with depression, but I did not have the adequate terminology or vocabulary to know how to voice what I was struggling with. I also felt very ashamed and kept much of my struggles to myself. In my early mental health recoveries, my therapist worked with me on voicing my needs and thoughts little by little. I struggled verbally growing up, so it took me finding my voice through writing and art to truly accept recovery and embrace my identity in due time. I am proud to accept help and have been mostly stable these past five years with the support of proper medication protocol, community support, and therapy. While I did not have access to help as a child before my teenage years or understand the depths of my mental illness healing until my adulthood, I am grateful for the emerging research today and aim to help the next generations find their voice and embrace who they are as they seek healing. Art therapy is a wonderful resource and can aid in the healing process. Having art therapy groups as a teenager and young adult helped me begin to find my voice. Without art therapy, I would not be the advocate that I am today. I found that altered books, blackout poetry, and painting were a few methods that helped me in expressing myself. I relate to some of the case studies I discuss here as feeling safe in my body and environment was the foundation of utilizing art therapy and finding healing in time.

Intersection of Typical Developmental Expectations

Art therapy is increasingly becoming more well-known and utilized in mental health treatment. A child struggling with mood swings can use art supplies to express their innermost fears, anger, frustration, sadness, and more. The article “Naming the Enemy: An Art Therapy Intervention for Children with Bipolar and Comorbid Disorders” delves into the research of the complications in treating bipolar disorder with comorbid disorders in children. The author examines a few case studies and explains that bipolar disorder is heavily comorbid with attention deficit disorders, particularly Asperger’s. There is an overlap of social anxiety that bleeds into “reoccupations with routines, rituals, and complex obsessive-oriented interests (that may border on delusions); while also cycling between moods” (Henley, pg.105). Our understanding of bipolar disorder in children is that there may be chronic mood swings where the child shifts rapidly between states of euphoric-like mania, irritability, depression, and more. In children, it is known for natural variations of mood that occur due to puberty. Especially in young girls, their menstruation can introduce mood swings and levels of irritability. Following the diagnosis criteria and ruling out these healthy, normal occurrences during the teenage years is imperative in correctly diagnosing a child with bipolar disorder.

The theoretical roots of developmental crises and trauma point to the importance of theories like Erikson on Identity Formation. This theory is crucial in the development of children as many go through the eight stages, six of which occur in adolescence. Identity Formation theory best explains the conflicts that children face, which lead to two opposing outcomes. The importance of this theory lies in how development continues over one’s lifespan and that social and interactional goals pertain to each stage, where various conflicts arise at each stage as well.

Research/Best Practices

The research of utilizing art therapy as a treatment protocol in the stabilization of bipolar disorder includes having the client follow a structured schedule, abide by a list of session rules and expectations, and be provided the space to speak up and practice body autonomy. In a case study by Lefebvre, the client, a young boy, was asked to create a superhero drawing. Before beginning, he surprised the art therapist with his great insight that sometimes it takes time for him to calm down, but once he can calm down and stop pacing, he will be ready (Lefebvre, 2008, p. 29-31). It is not always the case in therapy where the client is able to hold such insight, especially for children. However, the therapist sought out clear boundaries, open communication, and invited the client into the space with care and compassion. We see that when a therapist can establish structure, a clear guide of rules, and space to practice autonomy where a client can begin to feel safe enough to open up.

In addition to this understanding of a client’s coping, understanding the basis of the child’s development is essential in this conversation. As noted before, Erikson has a useful theory on how identity forms. Using this case study, we can refer to the stage of trust versus mistrust and see that once the therapist establishes rules and boundaries, the client conveys a level of trust and respect for the therapist and their space. The client obliges once the therapist calms him down and gives him space to engage in the activity. We may see in future sessions that the client may withdraw trust and test the therapist to see if they truly care. This theory later explores identity versus identity confusion, which is known for the child to feel self-conscious. In session, the client was quick to follow the directions and draw a superhero. As the client grows up, he may appear sheepish to the therapist and may not be so proud to show her his artwork anymore. We may see a dip in self-esteem, which also can be exacerbated by the early stages of the development of bipolar disorder. These stages of how identity forms are essential to know in looking at adolescents and their growth and development.

Art Therapy Interventions

In a study by Prager, their research includes “attempts to correlate stylistic features of art produced by these individuals to the characteristics of these disorders (Ulman, 1975). The iconographic study of overt symbols, their frequency, sources, and uses by a specific population or particular diagnostic group has been undertaken in other art therapy research” (Prager, p. 17). In this study, content, color, composition, line, mood, and energy were observed in clients’ artwork when in states of both mania and depression. The artwork in mania tends to convey great energy and rapidity while the artwork in depression shows dullness and low energy levels. The stylistic differences portrayed in each state of bipolar disorder lend to the idea that we can sometimes take cues from artwork and note when a child may be struggling emotionally. In fact, there are known artistic abilities for each age group, such as how a 4-year-old will begin to learn how to draw stick figures and otherwise cannot conceptualize the human form in artwork before that stage in child development, according to Lowenfeld’s Developmental Stages of Children’s Art. The artwork in this study shows the beginning stages of that 5 to 7-year-old development where they can begin to conceptualize people in drawings and process at the appropriate stage of development. In the Preschematic Stage, from ages 4-7, the beginnings of graphic communication is utilized and adults can better understand a child’s artwork. Color, space, and motivation continue to be utilized in this stage as well. The Schematic age, which is ages 7-9, can rely on a schema, where the child depicts something over and over again when special meaning is involved. At this age, the development of deeper empathy and a less egoecentric perspective is demonstrated, too.

Studying the development of bipolar disorder in trauma survivors, the research on how art therapy interventions can help alleviate trauma symptoms relates to the co-morbidity of BPD, which is a known manifestation of trauma in the mind. The article “The Effectiveness of Art Therapy in the Treatment of Traumatized Adults: A Systematic Review on Art Therapy and Trauma” explores how art therapy interventions significantly decreased “trauma symptom severity after a trauma-focused mandala drawing intervention in the study of Henderson et al. (2007) and the significant decrease of trauma symptom severity after the non-trauma-focused art therapy intervention (drawing after reality) in the control group might point at the effectiveness of both interventions (Schouten, pg. 223). It was found that trauma symptoms decreased significantly utilizing art therapy in addition to psychotherapy treatments such as EMDR or CBT. As noted in “Expressive Therapy With Traumatized Children,” Klorer explains, “Therapists should be trained in multimodal approaches, and trauma therapy should be individualized for the situation and the specific child. For the alleviation of PTSD symptoms in a simple trauma, cognitive behavioral approaches combined with art therapy are highly effective” (Klorer, pg. 4). This recent understanding gives us hope, notably for the children who grow up facing bipolar disorder and co-morbidity such as PTSD or BPD, as art therapy as a treatment can help alleviate the troublesome symptoms. For children facing these newly developing symptoms, early intervention is necessary. The earlier the symptoms are caught, the sooner the client can get on a path of healing. In facing their struggles early on, they can thrive in academic and social settings so they can enjoy their youth to the fullest and naturally evolve through their healthy stages of childhood development.

Summary

Overall, the research is consistent on this topic: art therapy as a treatment for children facing bipolar disorder can be of great help. Early intervention is important, although professionals see that there is also a need for labeling a diagnosis as a differential diagnosis as a way to give space that there may be co-morbid mental illness, or for the fact that it may be too difficult to decipher with multiple mental illnesses and mental disabilities coinciding with the perceived diagnosis criteria. Providing structure, rules and expectations, and a safe, welcoming environment with room to grow can aid clients in their healing and help build a healthy relationship with their therapist. Following children into their adulthood on their path of healing from trauma, it is significant to note that art therapy can be a therapeutic process for trauma survivors. With the knowledge that up to 50% of those with bipolar disorder may also have PTSD, we can better equip clients with more effective treatments, ideally CBT, EMDR, and/or art therapy. Our readings echo that including routine, safety, and flexibility in sessions can best support clients in healing from mental illness.