یک مطالعه موردی در مورد اثرات درمان خلاق هنری با کشش و راه رفتن مراقبه؛ تمرکز بر روی بهبود ابراز هیجانی و تخفیف علایم جسمانی در نوجوانان با ضعف اعصاب

Abstract The purpose of this study is to investigate how the creative art therapy with stretching and walking meditation can improve the emotional expression of a neurasthenic adolescent and alleviate her somatisation symptoms. The subject is a female third-year high-school student in D city in South Korea. The art therapy programme was conducted from 22 July 2012 to 30 August 2012, 3–4 times a week, for a total of 21 therapy sessions, with each session lasting 40–90 min. The following research tools were used in this study: a measure of alexithymia as a cognitive-affective disorder, and a measure of somatisation symptoms pre-test and post-test with a follow-up test were conducted and the results were compared. A content analysis of every session was also conducted. The results are as follows. First, creative art therapy led to an improvement in the emotional expression of a neurasthenic adolescent. Second, creative art therapy alleviated somatisation symptoms in the neurasthenic adolescent. The follow-up test revealed that the effects of the therapy continued beyond the treatment period. In conclusion, the creative art therapy with stretching and walking meditation improved the emotional expression and alleviated somatisation symptoms in a neurasthenic adolescent.

Introduction Most South Korean adolescents experience stress stemming from academic performance, career questions, interpersonal relationships, and other issues. In South Korea, due to the lack of a leisure culture, the prevalence of a university entrance oriented education system, and an authoritarian social structure, adolescents are often forced to suppress stress rather than express it. As a result, the level of complaints about somatisation symptoms for adolescents in South Korea is relatively high (Lee, Choi, & You, 2000) compared to other countries. Among the somatisation symptoms in adolescents are headache (10–30%) and stomach-ache (10–25%). Following these symptoms, there are tiredness, dizziness, nausea, chest pain and numbness of the hands and feet (Garber, Walker, & Zeman, 1991). Somatisation symptoms in adolescents are affected by age, gender, family features, social and cultural factors (Sin, 2003). However, alexithymia affects somatisation symptoms in adolescents more than any other factor (Barsky and Kleman, 1983, Karton et al., 1982, Romano and Turner, 1985 and Sin, 2000). This is confirmed by research results showing that 59% of adolescents with somatisation symptoms are unable to express their emotions (Bailey and Henry, 2007 and Park et al., 2008). These findings demonstrate that alexithymia acts as the main cause of somatisation symptoms (Hunter, 1979). Adolescents with somatisation symptoms caused by alexithymia become isolated from their peers or display aversive behaviour. These symptoms also interrupt their studies, relationships with friends, their adaptation to school life, and cause other social problems (Sin, 2003). Furthermore, young people who experience somatisation have the potential to develop into adults with somatisation disorder (Bass & Murphy, 1995). Therefore, it is very important to implement a treatment to alleviate somatisation symptoms in adolescents who have difficulties in expressing their emotions. Most previous studies of alexithymia in adolescents and symptoms of somatisation mainly analysed the main causes of somatisation symptoms or presented theoretical research on the correlations between symptoms and alexithymia (Barsky and Kleman, 1983, Karton et al., 1982, Romano and Turner, 1985 and Sin, 2000). Other studies focused on analysing the prevalence rates of these symptoms (Bailey and Henry, 2007, Ham and Park, 2005, Park et al., 2008 and Sin, 2000). As a result, relatively few studies assessed therapeutic approaches to alleviate somatisation symptoms in adolescents caused by alexithymia. To address the lack of studies in this area, this study proposes the use of a form of creative art therapy to alleviate somatisation symptoms in adolescent caused by alexithymia. Creative arts therapy can help individuals understand and resolve their psychological struggles and emotional states and to resolve them to restore harmony through creative activities. Creative art therapy offers various expressive materials and related methods that focus on supporting subjects to engage freely in artistic activities. Engaging in freely artistic activities allows subjects to express their suppressed emotions and eases their tensions. Therefore, this study proposes the implementation of creative art therapy to improve the expressions of emotions and to alleviate somatisation symptoms in a neurasthenic adolescence. The objectives of the research are listed below. 1. To investigate whether the creative art therapy with stretching and walking meditation improves the emotional expression ability in a neurasthenic adolescent. 2. To investigate whether the creative art therapy with stretching and walking meditation alleviates the somatisation symptoms in a neurasthenic adolescent

Results The results of the pre-test, post-test and follow-up test The measurement of alexithymia The subject scored 73 points on the alexithymia pre-test, 45 points on the post-test and 41 points on the follow-up test. In the pre-test, the score of 73 indicated that the subject had difficulties in expressing her emotions. However, in the post-test, the score of 45 demonstrated that the subject was now able to express her emotions. Moreover, the reduction of the score by 32 points according to the follow-up test indicated a further improvement in the ability of the subject to express her emotions and feelings (Table 1). Table 1. Results of a comparative analysis of the measurement of alexithymia. Pre-test Post-test Follow-up test 73 45 32 Table options Measurement of somatisation based on the Symptom Checklist-90 Revision (SCL-90-R) The subject scored 43 points on the Symptom Checklist-90 Revision pre-test, 23 points on the post-test, and 25 points on the follow-up test. The score of 43 indicated a high level of somatisation symptoms. However, the reduction of the score by 20 points on the post-test showed that many somatisation symptoms were alleviated. Also, the score of 25 on the follow-up test demonstrated that the subject was relieved of many of her somatisation symptoms (Table 2). Table 2. Results of a comparative analysis of the measurement of somatisation based on the Checklist-90 Revision. Pre-test Post-test Follow-up test 43 23 25 Table options Body image test When the results of the body image test were analysed from the point of view of improving the subject's ability to express emotions, the results of the pre-test showed that the subject was unable to express her emotions – as all of the parts of the body that were in pain were coloured by her in a very dark hue. In the post-test, the subject coloured the parts of the body that were in pain in orange – a colour associated with warmth. She described it as “an image of walking in the park.” She also said calmly, “It is like feeling the soft air around my body.” In the follow-up test, after colouring the entire body image, the subject reported that it was an image of her “walking in the park and singing merrily.” While in the pre-test there were no emotions expressed, in the post-test and follow-up tests an ability to express emotions and feelings was demonstrated. According to the analysis of these results in relation to somatisation symptom relief, in the pre-test after colouring the entire image in brown, the subject placed black dots on the parts of the body that had somatisation symptoms – the head, hands and feet, and chest. In the post-test, however, after colouring the entire body image in orange, the subject drew a pink aurora around it. Then, she said, “My symptoms were relieved and my body became warmer.” In the body image, she coloured the chest, and hands and feet – body parts where she previously felt somatisation symptoms – deep orange. In the follow-up test, the subject reported that “headaches and numbness in hands and feet have disappeared.” She coloured the entire image of the body in yellow and called it “a shining body.” She also said that she “I feel peaceful” and painted grass in the background. To summarise, in the pre-test, the subject used dark colours to denote in the image the parts of the body where she felt somatisation symptoms. However, in the post-test, she used a bright colour, indicating that she felt relieved of some of her somatisation symptoms. Moreover, in the follow-up test, the subject did not use any particular colour to highlight the parts of the body experiencing somatisation symptoms. Therefore, it is possible to argue that these symptoms disappeared (Fig. 1). Comparison of the results of the test. Fig. 1. Comparison of the results of the test. Figure options Analysis of the creative art therapy sessions The semi-structured programme of creative art therapy aimed to improve emotional expression and alleviate somatisation symptoms in a neurasthenic adolescent. It consisted of initial, intermediate and advanced stages. In order to promote physical relaxation, the subject listened to meditative music during the introduction section, and each session lasted for about 10 min. She was encouraged to move her body to follow the flow of the music. Detailed descriptions of each session are given below. Initial stage (sessions 1 to 3) The initial stage was dedicated to investigating the subject's mental state and family situation and to build up rapport. At this stage, to encourage the subject's creative activities, she was allowed to choose the materials and express her emotions through this medium freely. Session 1: A family system diagnosis was done with the subject and her mother. First, in a nonverbal family drawing exercise, the subject's mother drew a seaside with a seawall. The subject observed her mother's drawing for a long time and then drew a tissue box. Next, the subject, on her own initiative, called the drawing “rubbish” and said that she did not have any feelings about it. In the following verbal family drawing exercise, the subject drew an apartment building based on the advice of her mother. As with the first drawing, the subject stated that she did not have any feelings about it. Session 2: Body drawing was done during this session. First, A3-size paper and 24 colour crayons were offered to the subject. The subject was asked to choose her favourite colour crayons and close her eyes. After that, the names of each part of the body were called out to the subject, and she was asked to draw curved lines on the paper with her eyes closed. The subject was surprised to see that body parts where she experienced pain were coloured in a dark hue. However, she did not say anything about her feelings on this. Session 3: A family of fish was drawn. First, a fish tank was drawn and then father, mother, older brother and the subject were drawn (in the order described). Describing the drawing, the subject said that “the fish dispersed and everyone was doing his or her business.” During this session, the subject spoke about her family, and complained about somatisation symptoms caused by the conflict with her mother. For the first time, the subject expressed her emotions as she cried loudly while being encouraged by the emphatic understanding and support from the therapist. Intermediate stage (sessions 4 to 13) The intermediate stage focused on the subject expressing her feelings through language and body movements. In this stage, to help the subject to express her emotions easily and naturally, a theme for each sub-stage was introduced. In every session, after the subject chose and implemented various themes and materials to produce a piece of work, she was asked to express her feelings about the work she created using language and body movements. (1) Sub-stage 1: We focused on taste and implemented the same process in every session. Session 4: A sweet taste was chosen. According to the subject, “Sweetness tastes sugary. It is associated with sugar, candy and chocolate, and is like an endorphin.” Also, with a cheerful look, the subject draw a circle with both arms as she turned, going around the therapy lab once. Session 5: A sour taste was chosen. The subject said that “the sour taste is associated with oranges.” As she said this, she swallowed her saliva. She also said that felt “fresh like a new student,” and while she was saying this she grimaced and swallowed her saliva again. After that, she raised both arms in the air and swayed her entire body from left to right as she sat down and stood up repeatedly. Session 6: A spicy taste was chosen. According to the subject, “It is associated with a hot taste. It feels like your stomach is melting-like when you have a burning feeling in the stomach after getting very angry.” When asked about her feelings, the subject said, “I feel like when I am in the situation in which my parents, teachers and friends cannot understand the fact that I am too sick to go to school.” She then said, “I feel relieved because I can my express feelings about it – as if a pipe that was blocked inside was suddenly unblocked again.” After that, the subject opened her eyes wide and stuck her tongue out of her mouth as she shook her hands and jumped up and down. Session 7: A bitter taste was chosen. According to the subject, this taste was so bitter that it “felt like my tongue shrivelled.” As she said that, she grimaced, slightly bent her waist and assumed an awkward posture. The subject was surprised to discover that she assumed such a posture and said that she felt better and had “acquired hope that I could do something.” (2) Sub-stage 2: This state was focused on the four seasons and implemented the same procedures used in sub-stage 1. Session 8: Spring was chosen and was expressed like a mother's bosom. Among various materials offered to her, the subject chose B4-size paper, coloured paper, scissors, and glue. She put them on the table and sorted the coloured paper based on the seasons. Next, she chose paper in pastel colours and cut and glued flowers, a heart, and round shapes onto the B4-size paper. She described her work as something that “resembles a mother's warm and soft bosom.” Session 9: Summer was chosen and was expressed as waves. The subject said, “Summer is hot and active, and makes me feel young and passionate.” After saying this, she moved her arms with a cheerful look, as if she was engaging in a physical exercise, and went around the therapy lab twice. Then she said, “Suddenly I remember a dangerous situation in my primary school years, when I fell into the ocean while I was having fun in the water.” She said, “Falling into the water had scared me at that time; however, now this fear has disappeared and I feel refreshed as I draw the waves.” Session 10: Autumn was chosen and was expressed as fallen leaves. The subject said, “Autumn is a time of fruition and, at the same time, it is the season to prepare for winter. Therefore, it gave me a lonely feeling of solitude.” Subsequently, without any expression on her face the subject raised her arms and waved them to show the falling leaves. Then she remembered something that happened to her when she was a middle-school student. She said, “When I stayed for Korea's Thanksgiving Day at my maternal grandparents’ house, I witnessed an argument between my mother and uncle and aunt. While watching that scene, I felt that I looked like falling leaves, lonely.” Session 11: Winter was chosen and was represented as crystals of snow. The subject said, “I feel like my body shrinks, and I feel cold, lonely and isolated.” Without any expression in her face, she sat down and assumed a posture as if she were going to sleep for a long time. When spring came, she woke up from her sleep and stretched and started to move. Then, she said, “My shrunken heart is open and I feel fresh in my soul.” (3) Sub-stage 3: First, we talked with the subject about different feelings. A particular feeling was then chosen and a medium for expression was chosen as well. The feeling was expressed as a work of art and the subject was asked to describe her feelings about it verbally. Session 12: Cards with feelings written on them were presented to the subject and a talk about feelings and emotions was carried out. The subject was then asked to express the feeling or emotion that she felt most often in her daily life. The subject said, “The emotions I feel most are joy, sadness and anger.” She drew three circles with crayons on A4-size paper. In the circles, she drew a smiling face, sad face and angry face. After that, she wrote the following under each drawing as she described them. “The smiling face means I am smiling in a family photograph when we went on a trip to Europe, when I was a fifth-year pupil.” “The sad face shows how I feel when nobody understands my headache and dizziness.” “The angry face is an expression of anger when my mom and grandmother argue.” After that, the subject said, “I feel better after talking about my emotions, which made me feel upset in my stomach and feel pressure in my chest.” Gladly, the subject said, “Although I thought I would not be able to express that, I was wrong. The problem was I did not have anyone to express my emotions to or any chance to do so. It was not an inability to express my feelings.” Session 13: Session 13 was a continuation of Session 12. The subject was asked to express anger. She closed her eyes for a moment and remembered the time when she felt most angry. Then, she took out a piece of paper with a volcano drawn on it. This was how she expressed anger. First, she drew flames with an orange crayon and erupted lava, then she coloured in red on top of it with her hand pressing the crayon against the paper strongly. After she finished, she attached the drawing to the wall and looked at it. She said, “I feel relieved and suffocated at the same time.” After hearing the subject's words, the therapist asked her to make changes in the picture to make her feel relieved, or to draw a new picture that would make her feel so. Following the therapist's words, with a red crayon, the subject drew a volcano erupting violently on a new piece of paper. As she drew, she pressed the crayon even harder against the paper. She said, “Even if I feel pain in my hand, I feel relieved.” Advanced stage (sessions 14 to 21) The advanced stage focused on improving emotional expression and recovery bodily sensations. Furthermore, it concentrated on promoting positive self-awareness and discovering one's potential. (1) Sub-stage 1: To improve emotional expression and to recover bodily sensations, walking meditations were implemented. Through the walking meditations, bodily sensations in the feet were stimulated. The subject was asked freely to express the feelings and thoughts she received from nature and the surrounding objects. Session 14: The subject started at the park entrance and walked on a ground path. After walking for about 2 min, she sat on a bench and breathed deeply. At that time, she remembered times she took a walk with her mother, “As mom start nagging saying that I should be careful, should drink water etc., she made me forget the fact that I was actually taking a walk.” The subject also said, “Taking a walk with the therapist made me feel better and more peaceful than taking a walk with my nagging mother.” Session 15: After stretching and doing some walking exercises, the subject sat on a bench and breathed deeply. As she did so, she saw an angry child taking a walk with her mother. She said, “I remember when I was angry as a child. Once, when we went on a picnic in my nursery, a mischievous child threw grass into my lunch box. I was angry, but could not say anything, just hid my feelings secretly.” After hearing her words, the therapist re-enacted the experience the subject had in the nursery. The subject said, “I feel relieved,” and laughed. Session 16: In the school playing fields, the subject did stretching and deep breathing exercises. As she breathed deeply, she said, “When the body is tired, everything is tiresome, and I feel like I cannot do anything.” After hearing these words, to inculcate positive thinking, the therapist said, “As soon as you have such thoughts, you should shout “Stop” to yourself, and say “I can do it. I am the master of my body and mind. I control myself.” Session 17: As the subject did her walking exercises on the school playing field, she reflected on how she implemented in practice the therapist's advice on positive thinking that she received during the previous session. She said, “In the same way as I write in my diary, I wrote that I was grateful for the fact that I was born, and did well. I was grateful for my existence. As I wrote that, I could reduce other types of thinking.” Session 18: After doing stretching exercises in the park, the subject reported that she had had a sudden thought as she walked. She said, “I remember when I was a child how I cried a lot as my over-playful older brother teased me too much. I also remember that he crept into the house at night like a thief, so I was so scared. Even now, if I hear any noise at night, sometimes I feel terrified.” The therapist suggested a method to cope, “The reason why even now you feel the fear and terror that you experienced as a child is because you still remember them from your childhood. As soon as you understand this, these feelings of fear and terror should gradually disappear.” (2) Sub-stage 2: creative art activities were implemented to improve the subject's positive self-perception and to help her discover her potential. Session 19: After the subject was asked to think about herself, she was encouraged to express herself using different materials. First, she chose differently coloured papers. She chose light-purple and dark-purple paper and cut circles from it. Then, she chose red paper and cut flower petals from it. On an A4-size sheet of paper, she glued the purple circles and flower petals to create a mandala shape. Then, to complete the picture, she drew light with an orange highlighter. After she finished the picture, she looked at it and clapped her hands saying, “It looks pretty. I am like a pretty flower that bloomed in the mud and that is starting to emit light.” Session 20: The subject expressed her dreams as she explored her desires. She used a ruler on A4-size paper to draw a rectangle. Then she used acrylic paint to fill it in, very diligently. After the paint dried, she glued photographs that she had cut from a magazine inside the rectangle shape that she had coloured. First, she held the photograph to lips saying, “From now on, I will say with confidence what I feel in front of others.” Then, as the subject glued a photograph of a model with an imposing appearance, she almost shouted, “Even if I feel sad, lonely or scared, I can do it.” After that, as she glued a photograph of a very famous male designer, she said, “My dream is to become a famous designer.” The subject was most focused when she worked on expressing her dreams, and she felt happy when she finished her artwork. Session 21: To convince the subject that someday her dream could come true, this session focused on expressing oneself as a confident individual. First, an angry person was drawn on a sheet of A4 paper. After writing the word “No” under the picture with a black marker, the subject shouted, “Go away from me,” and threw the picture aside. Then, the subject drew a smiling person on another sheet of A4 paper, coloured it and wrote “Yes” under that. With a smile, she said, “Yes. Nice.” She happily added, “It is a picture of me being a university student.” This was the subject's vision of herself one year later. The subject said, “I feel surprised that I can express my emotions and feelings creatively. I am also very talented. To demonstrate my talent, I want to enter a college to study design” (Fig. 2). Results of the creative art therapy sessions. Fig. 2. Results of the creative art therapy sessions.