Child Adolesc Psychiatric Clin N Am

11 (2002) 343 – 364

Art therapy, psychodrama, and verbal therapy

An integrative model of group therapy in the
treatment of adolescents with anorexia
nervosa and bulimia nervosa
Lisa Diamond-Raab, MA, LPC, ATR, CP*,
Joan K. Orrell-Valente, PhD
Department of Psychiatry and Behavioral Sciences, Children’s National Medical Center,
111 Michigan Avenue Northwest, Washington, DC 20010, USA

‘‘Yes, Master’’
Even though it could make me die
‘‘Yes Master’’ is my reply
Serving as a slave
Going to my grave
My illness, Master, whom I serve
Even though I don’t deserve
To suffer this pain
‘‘Yes, Master Anorexia’’ is in my brain.
I can’t break free, I’ll surely die
‘‘Yes, Master’’ is all I can say
Serving my Illness day after day
—Written by 14-year-old girl on day 18 of her 32-day hospitalization
In this article the authors describe an approach to group therapy that integrates
art therapy, psychodrama, and verbal therapy in the treatment of seriously ill
patients with anorexia nervosa (AN) and bulimia nervosa (BN). AN and BN
typically afflict individuals in adolescence, with peak ages of onset at 12 to 14
and at 18 [10]. For normally developing adolescents, this is a period of radical

* Corresponding author.
E-mail address: lraab@cnmc.org (L. Diamond-Raab).

1056-4993/02/$ – see front matter D 2002, Elsevier Science (USA). All rights reserved.
PII: S 1 0 5 6 - 4 9 9 3 ( 0 1 ) 0 0 0 0 8 - 6
344 L. Diamond-Raab, J.K. Orrell-Valente

change physically, emotionally, cognitively, and socially, with the main psychic
thrust toward separation and individuation [18]. It is a time when secondary sex
characteristics develop, when emotions become more complex, when abstract
and hypothetical thinking evolve, and when peer affiliations assume great
significance [1]. For adolescents with AN and BN, however, development across
these domains becomes severely warped. Just as their bodies regress, their ability
to think abstractly is thwarted, their range of feelings becomes restricted, and
their social world shrinks.
To understand and treat AN and BN, it is necessary to move beyond the strict
DSM-IV criteria to a more complete picture of the emotional and cognitive
manifestations of these diseases. In doing so, the challenges to traditional
treatment modalities and the need for innovation in intervention techniques
become eminently apparent.

The emotional and cognitive manifestations of anorexia nervosa and

bulimia nervosa

Anorexia nervosa
Patients with AN lack awareness of the pathologic condition that holds them
hostage to the patterns of thinking, feeling, and behaving that serve their all-
consuming objective: starvation. They are usually in treatment against their will,
at the behest of parents and doctors. The initial stages of treatment are marked by
denial of any problem, disavowal of the illness, and resistance to change. Patients
expend almost all of their energy and time in an unrelenting effort to convince
themselves, and everyone else, that they are ‘‘just fine,’’ as evidenced by their
generally overdisciplined regimens, including overzealous academic performance
and overactive school involvement.
Patients’ lives revolve around ingenious plans to monitor their caloric intake.
They meticulously account for every calorie consumed and expended and
construct elaborate systems to avoid detection by parents and other concerned
parties. It is important to note that this dogged focus on calories and weight
control functions to defend against feelings.
Not surprisingly, the controlled setting of inpatient treatment is anathema to
them, with its focus on weight restoration and psychosocial interventions to
foster insight and change. Yet these patients often present as falsely cheerful
and can express little or no emotion [22]. Because they are typically bright and
articulate, they rely primarily on intellectualization as their defense mechanism
and can frame their experiences only within those terms. In traditional group
therapy, they are often withdrawn and reluctant to engage with others. They
seem emotionally cut off, completely unable to access and talk about feelings.
The goal in treatment is to help them become aware of, understand, and
integrate their emotional experiences with their concrete world to achieve a
more coherent sense of self.
 L. Diamond-Raab, J.K. Orrell-Valente 345

Bulimia nervosa
As with AN, BN functions as a defense against unwelcome emotions. Like
persons with anorexia; individuals with bulimia have poor self-esteem and
obsessive thoughts regarding their bodies. They also have a fragmented sense
of self, crave approval, fear rejection, and tend to self-isolate. A pathognomonic
feature of this illness is the struggle to regulate impulsive behavior, as manifested
not only by binging and purging but also mood lability and self-destructive
behavior. Moods can range from severe depression to agitation and anxiety. Self-
destructive behavior can include alcoholism, drug abuse, and self-mutilation
[5,14]. Unlike persons with anorexia, patients with BN readily admit that they are
ill and need help. The therapeutic goals for these patients are to overcome
obstacles to emotional experience, gain access into hidden parts of the self,
strengthen healthier aspects of the self, increase social affiliation, and improve
self-esteem [2].

The use of art therapy and psychodrama in facilitating insight

The efficacy of traditional group therapy depends largely on the ability of
patients to express emotions through words [11]. An inherent clinical character-
istic of AN and BN however, is alexithymia, the inability to put emotions into
words. Patients think concretely and often have no awareness of discrete
emotions, particularly the emotions that make them feel defenseless (eg, fear)
or aggressive (eg, anger). This lack of awareness may extend also to emotions
that represent connectedness (eg, love) [6]. Consequently, for this population,
insight tends to come relatively slowly in traditional group therapy. Patients may
have a sense of inadequacy and self-consciousness regarding their appearance
and abilities that supercede what is normal for teenagers. They tend to perceive
traditional group therapy as threatening [14].
Art therapy circumvents the psychologic barriers that traditional group therapy
may present. It is universally applicable and effective with patients of all ages,
developmental levels, and diagnoses [16]. The artistic media that are typically
used (eg, paper, crayons, paint, clay) are usually perceived as simple, familiar,
and nonthreatening [6].
Art therapy is particularly effective for patients who are alexithymic [11].
There is no immediate need for words. A potent mechanism in art therapy is its
ability to bypass entrenched verbal defenses, such as intellectualization, to evoke
directly psychologic and emotional responses. Patients also experience a sense of
control as they manipulate art materials and give form to chaotic inner
experiences [15]. Conscious and repressed thoughts and feelings are brought to
life and made concrete and accessible through color, form, and images. Patients
are able to play out their anger, conflict, sadness, and even their distorted body
images. An added benefit of art therapy, absent in verbal therapy, is the tactile
evidence (ie, patients’ artwork) of the change process [17].
346 L. Diamond-Raab, J.K. Orrell-Valente

Art therapy can be implemented individually or in the context of a group. In

the inpatient setting, patients typically work on individual art projects within a
group setting. As with traditional group therapy, each group member becomes a
therapeutic agent [9]. Members benefit from reciprocal feedback and social and
emotional support [21]. The group forum lends itself to social initiation and
relationship building.
Whereas the effectiveness of art therapy lies primarily in its ability to initiate
the therapeutic process through facilitating reification of repressed thoughts and
feelings, the effectiveness of psychodrama lies primarily in its ability to propel
the process forward by providing the opportunity for corrective repair [2,19].
Through enactment, the psychodramatist guides the patient, as protagonist, on a
journey of self-discovery [3]. Enactment typically spotlights an event or experience
that is causing distress, conflict, or fear in the patient. The event or experience may
have occurred in the past, may be ongoing, or may be expected to occur. Its
significance is attributable, in large part, to the patient’s inability to cope with it
adaptively [3]. With the psychodramatist strategically facilitating the process, the
patient is afforded, through enactment, the opportunity to view the event or
experience and himself or herself from various perspectives. The psychodramtist
guides the enactment of the event or experience to a point of resolution. Through
the process, patients can (1) reach a better understanding of the feelings that have
been somatized, (2) gain insight into other maladaptive ways of coping, (3) learn
and practice adaptive coping strategies, (4) learn and practice new roles, and (5)
achieve catharsis and a degree of psychic resolution of the event or experience [12].
Psychodrama serves as a microcosm of human experience and integrates ‘‘all the
modalities of living, beginning with the universals—time, space, reality, and
cosmos—down to all the details and nuances of life’’ [7].
The benefits of psychodrama accrue not only to the protagonist, however. The
protagonist works for the group not just for himself or herself. Given the
universality of the themes that emerge (eg, loss, fear, abandonment, rejection),
participants and witnesses often benefit in ways parallel to the protagonist [13].

Integrating art therapy, psychodrama, and verbal therapy in group therapy

In the tradition of Moreno [20] and Yalom [23], the current model integrates
art therapy, psychodrama, and verbal therapy in unique approach to group
therapy. It is grounded in the lead author’s 22 years of clinical experience in
acute care, psychiatric inpatient treatment, the past 10 years of which have been
devoted to the psychiatric inpatient treatment of adolescents. In this section, the
authors highlight key recommendations for structuring the group, outline a
prototypical group session, and provide an illustration.
The size of the group depends on the census on the treatment unit at a given
time; however, group size is an important factor in the effectiveness of group and
milieu therapy and should range from 6 to 12 [21]. The authors strongly
recommend that groups meet regularly, from three to five times weekly, in the
 L. Diamond-Raab, J.K. Orrell-Valente 347

same setting, at the same time of day, for no less than 90 minutes. All members of
the community of inpatients, as far as is possible, should be encouraged to
participate; however, if a patient’s thought processes are impaired, he or she
should not attend.
Group therapy sessions necessarily proceed along a defined trajectory that
reflects the larger therapeutic process. The group essentially moves together
through a prescribed psychologic space. Sessions are bounded by a clear
introduction, proceed systematically through successive stages, and finally lead
to closure. Once a session is underway, patients should not enter or leave;
however, self-imposed time outs are allowed.
The prototypical session comprises four stages: (1) creation of the holding
environment, (2) the warm-up, (3) art and/or psychodrama, and (4) sharing.

Stage I: creating the holding environment (or sacred space)

The session begins similarly at each meeting, with procedures designed to
provide a sense of predictability and safety to group members while also allowing
members a measure of control. Members sit in a circle, which reinforces the
literal and symbolic sense of safety and care that the hospital milieu evokes [25].
An important function of this stage is to begin to assimilate new members into the
group. ‘‘Veteran’’ members are invited to explain the purpose of the session, the
procedures, and the group expectations. Importantly, confidentiality is reviewed.

Stage II: the warm-up

The warm-up has been described as ‘‘a psychological and biochemical process
through which one becomes ready for an act’’ [13]. On an inpatient unit, in which
the members of the group are constantly changing, the warm-up is an imperative.
Therapeutic techniques that are used during this stage are designed to help group
members access and bring into the ‘‘here and now’’ critical events or experiences
that evoke distress. Bringing an event or experience into the ‘‘here and now’’ is to
imagine it as though it were actually occurring [24]. It becomes imbued with ‘‘the
dynamics of the present. . .and all its immediate personal, social, and cultural
implications’’ [7].
Warm-up activities are intended to (1) provide structure and direction to the
session, (2) allay group members’ anxiety and promote feelings of safety, (3)
allow group members to establish rapport, (4) foster group interaction, (5) convey
information about new and ‘‘veteran’’ group members, (6) facilitate spontaneity
by connecting group members to the ‘‘here and now’’, (7) provide the therapist
the opportunity to observe group dynamics and assess the level of functioning of
the group, (8) help group members identify what they need to work on, (9) allow
a group theme to emerge, and (10) facilitate group members’ self-expression and
self-exploration [3,4].
The therapist may use either a physical ‘‘starter’’ (eg, pieces of fabric, tarot
cards, rocks, crystals) or a mental ‘‘starter’’ (eg, dreams, fantasies) to initiate the
348 L. Diamond-Raab, J.K. Orrell-Valente

process. There is no immediate need for words; group members respond

viscerally to the ‘‘starters,’’ which serve to catalyze access to emotions, become
symbols of these emotions, and serve as bridges to cognitions and language [3].

Stage III: art therapy and psychodrama

Based on the therapist’s observations and the themes that emerge during
warm-up stage, the therapist decides whether to make a transition to art therapy,
psychodrama, or some combination of the two modalities. For example, if most
of the members of the group are new, reticent, and do not seem to be engaging,
the use of art may be most effective in initiating the therapeutic process. If,
however, group members are cohesive, clearly engaged with each other and the
therapist, and exhibit a high degree of affect over a specific theme, psychodrama
may be indicated. Similarly, under certain circumstances, both modalities may be
indicated. That is, artwork that has been created in the beginning of the session
may be brought to life through psychodrama.
Not surprisingly, patients with eating disorders experience distress regarding
food issues and the specter of their illness. They tend to benefit from enactment
of situations that may arise, such as their return to school, the cafeteria line, and
classmates’ scrutiny or the family dinner and the scrutiny of parents and relatives.
Patients also seem to benefit from enacting the intrusive and obsessive thoughts
that prevent them from eating; their images AN or BN as a dominant force within
them; or the role of food (wherein the patient may assume the role of the food)
and their relationship with it.

Stage IV: sharing

Although sharing occurs throughout the session, it is the primary modality that
is in operation during the final stage of the session. The therapist, attuned to
group members and group dynamics, moves the session forward, from the outset,
seeking to accomplish therapeutic goals through the use of strategic comments,
trenchant questions, and evocative interpretations. The goals in this stage are to
(1) help group members translate emotions into thoughts and words, (2) afford
group members the opportunity to talk about their reactions to their own and
others’ artwork or enactment, (3) help group members who participated in a
psychodrama make the transition from their roles back to reality, (4) allow group
members to reconnect and, through mutual empathy and identification, build
group cohesion, (5) facilitate containment and closure, and (6) provide the
impetus for succeeding sessions [13].

Prototypical example
During the warm-up stage, for example, the therapist scatters 12 to 15 pieces
of fabric of varying colors, textures, and scents in the middle of the room (eg, stiff
dark-green fishnet, soft white blanket, rough black burlap, fuzzy pink boa,
smooth red satin). The therapist then instructs group members to select—based
 L. Diamond-Raab, J.K. Orrell-Valente 349

on color, texture, and scent—the piece of fabric that reminds them of family
members with whom they have a conflicted relationship.
The therapist observes that a patient with AN selects the pink boa. The therapist
asks her to explain her choice and the patient hugs the boa to herself and states that
she selected the boa because it was pretty, soft, felt good, and represented her
family. She declares that she has no problems with any members of her family, that
her family is close, and that, in fact, her mother is her ‘‘best friend.’’ The therapist
does not challenge the patient’s denial, choosing to focus instead in helping the
patient gain a better understanding of her illness.
The therapist asks the patient if there is a piece of fabric that reminds her of
another kind of conflict. The patient reaches for the dark-green length of stiff
fishnet fabric, which she forces into the shape of a ball. The patient explains
that her struggle is with her eating disorder and that the fabric is like her
stuffed stomach, round, misshapen, and bloated. She adds that she had been
‘‘forced’’ to eat lunch and that she felt like a goose that was being fattened for
Christmas dinner. She further explains that she has intrusive, recurrent thoughts
that tell her unceasingly that she is fat, that she does not deserve to eat, that she
must not listen to family, friends, or doctors. At this point, the therapist asks
the patient if she would like to bring those thoughts to life through a
psychodrama so that she can identify and practice methods she could use to
cope with these thoughts.
The therapist directs the patient through a psychodramatic enactment. The
patient identifies three recurring thoughts and selects three group members to
personify the thoughts. She then lies flat on the floor with the balled-up fabric on
her stomach. Sometimes taking turns, sometimes in unison, the three auxiliaries
taunt her with the mantras of her eating disorder (eg, ‘‘You’re a fat pig,’’ ‘‘You
don’t deserve to eat’’). The patient acknowledges the voices and expresses
feelings of agitation and helplessness. She is encouraged to go beyond the feelings
and identify ways she can gain control of her thoughts through adaptive coping
strategies. She states that she could talk to a staff member, listen to music, write in
a journal, or draw. Group members are selected to represent each activity. The
patient is led again through the scene with the voices taunting her. This time, she
implements her newly articulated coping strategies. After this practice, the
therapist checks with the patient to ensure that it is a good point at which to
close out the enactment. The patient and other group members are then guided in
de-rolement, and all group members are invited back to form a circle for sharing.
During the sharing stage of the session, group members are encouraged to
reflect verbally on the thoughts and feelings that the psychodrama evoked in
them. An auxiliary verbalizes that his role is causing him to reflect about his
image of himself and his body. One group member reveals that she also has
intrusive thoughts that she has never shared with anyone. Another group member
shares that she experiences feelings of powerlessness when her father and mother
argue and call each other nasty names. The protagonist discusses insights she
gained from her enactment thanks the group for their support. The therapist then
closes the session.
350 L. Diamond-Raab, J.K. Orrell-Valente

Art therapy and psychodrama in the treatment of anorexia nervosa and

bulimia nervosa: a study in contrasts
In this section the authors describe the use of art therapy and psychodrama in
the treatment of a patient with AN and a patient with BN, charting the change
process through their artwork. Names have been altered.
As Figs. 1 to 10 illustrate, the artwork of the patient with AN stands in striking
contrast to the artwork of the patient with BN. The differences in style and
symbol are typical of the two populations [17]. Patients with AN tend to select
art-making materials that reflect their need for control and precision, preferring

Fig. 1. ‘‘Self-Portrait I.’’ Colored pencil and color fine-tip marker.

 L. Diamond-Raab, J.K. Orrell-Valente 351

fine markers, pens, and pencils. They tend to draw using a light hand and making
faint markings. Their drawings are usually of an organized, tight, lone figure, set

Fig. 2. ‘‘Pre-Divorce Family Portrait.’’ Color fine-tip markers.

352 L. Diamond-Raab, J.K. Orrell-Valente

Fig. 3. ‘‘Post-Divorce Family Portrait.’’ Color fine-tip markers.

precisely on the sheet of paper, with much of the rest of the paper untouched.
Figures are usually attractive but serious and strained in expression.
In contrast, patients with BN tend to select art-making materials that reflect
their inability to self-regulate, preferring paint, clay, and glue for use in the
construction of collages. Reflecting their impulsivity, they tend to be chaotic and
messy in style, wasting materials and cramming as much as will fit on a sheet of
paper [17]. Their artwork tends to be dramatic and angry and depicts unpleasant
themes such as abuse and self-harm.

Case study: 12-year-old girl with anorexia nervosa

Background information
At time of hospitalization, Amy had just turned 12. Weighing just 54 pounds,
severely malnourished, refusing food, depressed, and anhedonic, she was
diagnosed with AN and major depressive disorder.
Amy lived with her mother and 18-year-old brother. Her parents separated
when she was 9 but were still in the midst of a bitter, protracted divorce. Amy’s
mother, a homemaker, reportedly began to deteriorate after the separation. She
was diagnosed with major depressive disorder when Amy was 10; however, her
symptoms did not respond to psychiatric intervention and she became increas-
ingly dependent on Amy. Amy was forced not only to assume many household
responsibilities but also to become her mother’s caretaker.
 L. Diamond-Raab, J.K. Orrell-Valente 353

Fig. 4. ‘‘Self-Portrait II: Let Me Speak!’’ Colored pencils.

Family members reported that they observed no sign of distress in Amy when
her parents separated. She seemed to accept the situation and focus on school and
friends. As her mother’s condition worsened, she seemed to shoulder the
increased responsibilities thrust upon her without complaint. She also maintained
her excellent academic record.
With the onset of puberty, at approximately age 11, symptoms of AN and
depression began to manifest. As her peer group moved into the age-appropriate
developmental task of identity formation, when girls are drawn toward the
artifacts of adulthood in terms of make-up, hair, and dress, when they develop
close attachments to same-sex friends, and when they engage in early exploration
of opposite-sex attractions, Amy seemed to have regressed. The need in her
family for her to assume, prematurely, the inappropriate role of caretaker and
mediator seems to have disrupted Amy’s normal developmental trajectory. She
essentially had to deny her own needs, feelings, desires, and goals. She dared not
admit that she had any. Although she continued to perform her academic and
household duties, she began to shut down emotionally and socially, exhibiting
pathologic control over the only thing that she could control—her own body.
At time of admission, she was placed on the standard eating disorder protocol
and supplemental nocturnal nasogastric refeeding. She was initially resistant to
nutritional rehabilitation and traditional psychosocial interventions such as
individual therapy and family therapy. She saw no problem and felt she had
354 L. Diamond-Raab, J.K. Orrell-Valente

Fig. 5. ‘‘Self-Portrait III.’’ Colored felt-tip marker.

 L. Diamond-Raab, J.K. Orrell-Valente 355

Fig. 6. ‘‘Mask of Confusion.’’ Collage made of styrofoam and magazine clippings.

nothing to talk about. She was also isolative and refused to interact with peers on
the treatment unit. Art therapy, psychodrama, and journaling proved the most
effective treatment modalities with Amy.

Beginning of treatment
In the initial expressive group therapy session, Amy was impassive and
noncommunicative. Invited to draw a self-portrait, she drew herself in profile,
with nasogastric tube scratched out, head bowed, face enveloped in tears,
eclipsed by huge black question mark (Fig. 1). Her artwork conveyed a sense
of helplessness, confusion, sadness, and tension. Drawing herself in profile, with
356 L. Diamond-Raab, J.K. Orrell-Valente

Fig. 7. ‘‘Live or Die.’’ Collage made of magazine clippings.

a dark, closed mouth, she also communicated a fear of revealing all of herself.
Asked what she was hearing, she responded in a little-girl voice, ‘‘My parents
fighting.’’ Asked what she was feeling, she answered flatly, ‘‘Confused and sad.’’
This was her first, albeit tentative, admission of feelings of distress. She,
however, displayed no insight as to what might explain her feelings.
She subsequently drew a large bag, colored a beautiful rich purple. Belying its
appearance, she explained that the drawing represented the sad feelings she
wanted to throw out. It was apparent that she needed to cloak her distress in a
falsely outer layer. Again, she exhibited no insight. During this stage of treatment,
she also drew a family portrait (Fig. 2), depicting her family in a tearful group
hug. In the picture, she was 4 years old, the last time she could recall her family
as intact and happy. In the picture, the family was grieving because, as Amy
explained, they will never experience the family in that way again. Her artwork
was tightly controlled and precise. At this point in treatment, Amy was beginning
to eat minimally but continued to require nutritional replacements at every meal
and supplemental nocturnal nasogastric refeeding. Her mood remained depressed,
her affect flat.
At the next session, Amy’s mood was minimally brighter. At this session, she
revealed the reality of her family dynamics through her artwork (Fig. 3). Family
members were represented as disconnected, her father stood apart, anxious, hands
shoved deep in his pockets; her brother looked bewildered; her mother looked sad
and fragile, Amy placed herself closest to her brother but her self-representation
was relatively small and insignificant. Her arms were folded tightly around
herself, as if to keep herself protected.
 L. Diamond-Raab, J.K. Orrell-Valente 357

Fig. 8. ‘‘Chaos.’’ Collage made of magazine clippings.

358 L. Diamond-Raab, J.K. Orrell-Valente

Fig. 9. ‘‘Out of Control.’’ Collage made of magazine clippings.

Middle of treatment
Amy began to exhibit measurable improvement. Her mood was brighter, she
initiated positive interaction with peers, and she provided supportive and
constructive feedback during group therapy. During this period, Amy drew a
large black beast that she described as representative of her depression. She also
observed that it was this black beast that prevented her from swallowing. This
drawing provided a key opportunity for the use of psychodrama. Group members
assisted her in the enactment of the image of this beast. During the enactment,
Amy was able to articulate feelings of anger and, for the first time, she made the
connection between her feelings of anger, her depression, and her inability to eat.
She was encouraged by all to express her anger appropriately.

Fig. 10. ‘‘Imagine It!’’ Collage made of magazine clippings.

 L. Diamond-Raab, J.K. Orrell-Valente 359

At the next session, her affect was more introspective. Suggesting improved
insight, her artwork reflected her sadness regarding her parents’ divorce. At this
point, she experienced further insight when she identified that her anger was
caused by the role reversal that had occurred between herself and her mother.
Marking a turning point in treatment, Amy began to open up about feeling
caught in the midst of the conflict between her parents. She expressed that she felt
as though she was forced to choose between them. She also revealed that she felt
like ‘‘they put words into my mouth.’’ Her artwork suggested further that she felt as
though her own voice was silenced and that her parents and others tended to speak
on her behalf (Fig. 4). She expressed frustration that in family therapy sessions even
her therapist spoke on her behalf. She wanted to take back her own voice.
In a psychodrama to enact these feelings and images, Amy was provided the
opportunity to decide on, and to rehearse, what she wished to say to her parents in
a subsequent family meeting. In this enactment, she expressed her feelings,
practiced being assertive, and in so doing began the process of redefining her role
in the family. She was able to allow herself to experience the sadness that her
parents’ divorce evoked, express her resentment regarding the role of caretaker
that had been thrust upon her, and express her own need for parental care.

End of treatment
Around this time, Amy began speaking in a more mature tone of voice.
Surprising her peers, she volunteered to participate as an auxiliary in another
patient’s psychodrama, freely expressing her opinion.
In her final piece of artwork, another self-portrait, she drew herself still in
profile but with head erect facing forward, no nasogastric tube and no tears. She
replaced the oversized question mark of her first self-portrait with a huge
exclamation mark (Fig. 5). In discussing her new and improved self-portrait,
she explained that she had been able to unravel her feelings, to make sense of
them, and to gain a measure of self-confidence. She acknowledged and expressed
feelings of fear and apprehension surrounding her return to home and school.
In sum, after 27 days of hospitalization, Amy was eating her meals in their
entirety without need for nutritional replacements. She had achieved 95% ideal
body weight. She had learned to recognize, acknowledge, and express her
emotions. She was able to tell her parents what she needed from them. In family
therapy, her parents had come to understand, largely through Amy’s expression of
her feelings and needs, that their interpersonal hostility was manifesting in
triangulation of Amy. She also had been able to initiate and maintain several
peer relationships. She and her family also fully understood the need for
continued individual and family therapy.

Case study: 16-year-old girl with bulimia nervosa

Background information
Nancy, a 16-year-old girl, was readmitted for inpatient treatment after failing
the partial hospitalization program to which she had been discharged 1 week
360 L. Diamond-Raab, J.K. Orrell-Valente

earlier. She had been referred because of extreme weight fluctuations, ongoing
binging and purging, depressed mood, and escalating self-injurious behavior (eg,
burning the soles of her feet, burning and cutting her ankles, and cutting her
forearms). Her psychiatric history also included past alcohol abuse and, as she
later revealed, suicidal behavior.
Nancy’s parents divorced when she was 10. They shared physical custody of
Nancy, an only child. This custody arrangement had obliged Nancy to shuttle
back and forth on almost a daily basis between the two households. It was usual
for Nancy to leave for school from one home and return to the other home after
school. Symptoms of BN reportedly began to emerge when she was approx-
imately age 13. An eleventh grader, Nancy had recently transferred from private
to public school because she had felt like she ‘‘didn’t fit in’’ at the private school.
Nancy’s mother had been diagnosed with a remitting, recurring form of
multiple sclerosis when Nancy was 14. Although admittedly depressed for
months, her mother had not sought treatment.
Nancy presented as a tall, thin, well-dressed teenager, with short-cropped hair,
wearing baggy, masculine-style clothing. At time of admission, she was unable to
contract for safety. She was placed on the standard eating disorder protocol.
It was clear from the outset that Nancy was not willing to cooperate with
treatment. Displaying deep mistrust, she was belligerent with staff and peers,
proudly boasting that she had fired her previous three therapists and that ‘‘all
therapy is useless.’’ It was decided that because of her distrust of traditional
individual therapy and unwillingness to engage verbally, she would instead see
the expressive therapist for individual art therapy three times weekly. As with all
inpatients, she also attended expressive group therapy four times weekly.
Treatment goals were to help Nancy identify the precipitants of her self-
destructive behaviors, learn to feel comfortable expressing her emotions, learn to
express emotions appropriately, learn adaptive ways to regulate her emotions, and
gain access to the hidden parts of herself.

Beginning of treatment
Initially, Nancy exhibited no insight regarding the precipitants of her mood
and self-destructive behavior. She was also somewhat quiet and isolative.
Reluctant to draw or paint, she embraced the idea of creating collages by cutting
from magazines images and words that best conveyed how she felt and what she
wished to say then pasting them onto sheets of paper.
Her first task was to create a collage that represented herself. This collage
comprised a background of images of webs. Set in the middle of the webs was a
picture of a huge, black monster, which represented her dark mood and her image
of herself as a noxious creature trapped by her situation.
Fig. 6 depicts a subsequent piece created during her second expressive group
therapy session. Invited to create a mask depicting hidden parts of herself, Nancy
elected to use styrofoam as a base and immediately cut out an enormous question
mark. She then constructed the background of her collage and pasted on images
of various faces, with two words prominently displayed: ‘‘confused’’ and
 L. Diamond-Raab, J.K. Orrell-Valente 361

‘‘warning.’’ The enormous white question mark was superimposed over the faces.
This collage communicated eloquently that Nancy, because of fear, felt obliged to
keep herself apart and hidden. It also communicated her overwhelming sense of
confusion and intense guardedness. When probed, Nancy disclosed that although
she wanted to be more open, she feared rejection. She reported that she had felt
rejected by her teachers and peers when they discovered that she had BN. She
also revealed that fearing that she would be further rejected, she had tried to hide
her feelings of depression from her family and friends. She expressed that she
feared rejection from the group members and from the therapist.
Fig. 7 is a particularly powerful collage that required processing over several
individual therapy sessions. The dominant image, set in the middle of the page,
is that of a head that is half skeleton, half male. The eye of the skeleton
contains a lurid image of alcohol. Images of people laughing broadly crown the
head. Peripheral images suggest repressed anger and include a mummified
figure, a school bus, a disembodied eye, a gun, and a bowed human head with
a small flame set atop. Poignant phrases and words punctuate the collage (eg,
‘‘I dream of laughing’’, ‘‘don’t worry’’, ‘‘why’’, ‘‘feel’’). In discussing her col-
lage, Nancy spoke of her anger, her suicidal ideation, feeling trapped by her
fears, the overwhelming urge to cut herself so that physical pain would
‘‘relieve’’ her temporarily from her psychic pain, and her dreams of being
happy. She spoke of feeling half-dead, judged, and rejected. In addition she
described her own rejection of her femininity and her confusion regarding her
sexual identity.

Middle of treatment
As Nancy began to express her feelings through her art projects, her level of
comfort with herself, her peers, her therapist, and the milieu noticeably improved.
She began to trust the therapeutic alliance, became more sociable with peers, and
spontaneously worked on her collages. Significantly she was increasingly able to
express her emotions verbally and began to make progress in identifying the
precipitants of her self-destructive behavior.
A collage that she created during this period vividly illustrated the extent of her
anger and her identity confusion at this time (Fig. 8). The piece was dominated by
the partial image of a face, with the eye obscured behind sunglasses. Over the lens,
images of flames were pasted, and over the flames the word ‘‘battle’’ was attached.
Across the brow of the face, the words ‘‘How far would you go to become someone
else’’ were emblazoned. The rest of the piece comprises images of monsters, a
disembodied eye, more flames, and more words of despair.
This collage evoked wrenching emotion in Nancy. She expressed painful
feelings that she described as causing her to ‘‘constantly scream inside.’’ She
spoke of the parental ‘‘battling’’ that had occurred throughout her life. Her
parents fought over her because, ostensibly, they both loved and wanted her so
much. Ironically, their focus on this conflict precluded any focus on Nancy’s
needs. She felt invisible, unseen, unloved, and uncared for, and as she reported,
she consumed vast quantities of food to fill the void. These revelations caused
362 L. Diamond-Raab, J.K. Orrell-Valente

Nancy to feel vulnerable and she expressed self-hatred, hopelessness, and a desire
to run away.
About this time, Nancy was selected by a male peer to be an auxiliary in a
psychodrama to enact his family conflict. During the sharing stage of the session,
as Nancy de-roled, she disclosed that to avoid conflict, she had never revealed
her ‘‘real self’’ to her parents. She described her mother as ‘‘fragile’’ and her
father as ‘‘childish.’’
Shortly after this session, Nancy created another dramatic collage that also
required several sessions to process (Fig. 9). In this collage, a full frontal view of
a beautiful female face dominated the page; however, a grotesque, open mouth
crammed with boxes of Tylenol marred the image. Other images that were
included in this collage were a picture of a young film actress, a piece of cake,
and an open hand. At this point, she talked for the time of her prior suicidal
behavior that she had never revealed before. She also revealed ongoing suicidal
ideation. She expressed that she felt out of control, unable to control her rage. At
this point, she recalled that her parents had divorced because her father had had
an affair. She realized that that was the point when she first started to use food to
comfort herself and that she ‘‘ate and ate but could never get full.’’

End of treatment
Not coincidentally, as Nancy began to express increasingly her internalized
feelings, she experienced thoughts of self-harm less frequently and with less
urgency. Her urge to binge and purge also decreased significantly, and she
expressed a genuine desire to get well. She had achieved 100% ideal body
weight. She had come to feel safe in the hospital and had grown attached to her
therapist and to peers. She had emerged as a leader within the community of
patients; however, she expressed fear about discharge.
She was invited in group therapy to enact her fears regarding discharge. She
expressed fear about returning to her old patterns of behavior. The psychodrama
revolved around her return home and her return to school. Auxiliaries played the
role of her old impulses and behaviors calling to her, trying to control her. She
was afforded the opportunity to explore adaptive ways of controlling her
impulses and her feelings. She was able to experience a ‘‘catharsis of integration’’
[8]. Extremely upset after the drama, she explained that she had found it difficult
to look at what she had become and worried about who she would be without the
old patterns of behavior. At this point the focus of the session turned to her
redefinition of herself.
Fig. 10 is the final collage Nancy created while in treatment. The collage
depicted adaptive ways of coping: a running shoe, a sailboat, linked hands, a
kitten. She discussed making peace with her body, eating healthily, crying and
releasing feelings, confronting her parents, walking outdoors, practicing karate,
and laughing.
In sum, Nancy’s work in group therapy and in individual art therapy afforded
her access to deeply repressed feelings. She had learned not only to express and
interpret these feelings but also to manage them adaptively. She also had begun to
 L. Diamond-Raab, J.K. Orrell-Valente 363

regain her trust in the therapeutic process. She articulated the important insight
that her distrust was borne of her fear, not of fear of therapists or peers but of fear
of what she might find if she were to look within herself. She acknowledged that
she had not found the ‘‘monster’’ that she had expected to find. Notably, she was
able to say that she no longer experienced the self-loathing that had previously
overwhelmed her; however, she was not able, at the point, to affirm herself
actively. Conveying hope, she expressed a desire to live.
Importantly, in family therapy, Nancy was able to express the deep and
protracted distress caused by physical custody arrangements that had not taken
her psychologic well-being into account. At her request, it was determined that
she would live with her father and visit her mother alternate weekends.
At discharge, Nancy understood that discharge did not mean recovery and that
she needed to continue the work she had begun during her inpatient stay. She was
discharged to outpatient treatment with an art therapist.

Summary
Anorexia nervosa and bulimia nervosa typically afflict individuals in adoles-
cence. Given the intractability of these diseases in combination with the natural
recalcitrance of adolescence, treatment with this population presents a daunting
challenge. Traditional group therapy that focuses on verbal therapy is often not
effective with this population, particularly in the acute stages of the diseases. A
group therapy approach that integrates art therapy, psychodrama, and verbal
therapy offers an innovative alternative to traditional group therapy.

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