Sarah is sitting on the cream-colored carpet, dressed for the warm weather in cropped pants and a white cotton top. Her brown hair is cut short in a feminine but almost childlike style, her soft brown eyes giving the appearance of serenity, a quiet accessibility.

“I was raised in a Christian home,” Sarah begins. “I really do have very loving parents,” she hastens to add, hugging her knees to her chest. With no change in her facial expression, she continues, “As early as I can remember I was being abused by my older brother. Later I found out he was being abused by our grandfather.” Sarah’s grandfather, she reveals later, was a pastor.

Sarah (not her real name) connects this ongoing abuse, which ended just before she turned 12, with a years-long struggle with the eating disorder anorexia nervosa.

“I’ve struggled with body image all my life, since I was 5. It wasn’t until I was 20 that I went into major restriction [of food] … I had extreme body issues, and was basically worshipping skeletons.”

Sarah’s artwork is spread across the room, illuminated by the natural light of the brilliantly sunny day outside. Images of skeletons sit next to childlike drawings of large faces with oversized tears, or a single eye placed on a pedestal. In another drawing, an outline of a body is silvery and spare, with pink dots raining down around the figure. Above it reads, “BEAUTY INSTEAD OF ASHES.”

As the late French painter Georges Braque once said, “Art is a wound turning into light.” Art, or the making of art as a form of therapy, of healing, is now considered a central component in the treatment of eating disorders.

Selah House, where Sarah began her healing journey, is a residential treatment center for women suffering from severe eating disorders, including anorexia nervosa (restriction of food), bulimia nervosa (binge eating and purging) and non-specified eating disorders (ED-NOS). Sarah is one of the lucky ones: According to the National Institute of Mental Health, of all psychiatric illnesses, eating disorders have the highest mortality rate. Without treatment, 20 percent of those who are untreated will die. Of those who are treated, 2 percent will still die.

Sarah’s story is shared in one of the cheerfully decorated rooms of Selah House, where boxes of art supplies are plentiful, as are stuffed animals, passages from the Bible and plenty of upholstered furniture. There’s an inevitability to Sarah’s words, a grateful acknowledgement of art as a transformative force in her healing. “Art therapy is where I find myself,” she offers.

This is your assignment

As with many psychiatric illnesses and conditions, art is a way of guiding the individual towards the wellspring of authentic feeling: the place that is most often cut off, so often replaced by an addictive behavior or other negative coping mechanism.

Before seeking treatment for her anorexia, which for her manifested itself as a severe restriction of food and addiction to exercise, Sarah was not able to give rise to her genuine feelings, the ones that led her to the dark prison of self-imposed starvation. “I was completely disconnected from any feelings or emotions. I was pretty much dead emotionally. I would use that negative energy to hurt myself.”

Although she was resistant to making art at first, in treatment she discovered, “It was healthier getting it out on paper than taking it out on myself.” One of the defining characteristics of an eating disorder is the intense need to control. This creates a resistance to activities such as art, or other kinds of creative expression such as dance, that might open up the woman (or man) to the creative self, which is boundless and, by its very nature, uncontrolled.

Sitting on a nearby couch, Misty Rees, the program director of Selah House, witnesses Sarah’s story. Rees, having guided Sarah through treatment a year ago, also acknowledges her own story — one that brought her here, and that led her to become a certified art therapist and mental health counselor. Rees also suffered from anorexia and, like Sarah, her illness came to a head in college.

Rees, who was already versed in the language of art as a student in the art program at the University of Evansville, was making art in an academic setting, so its healing aspect was not yet clear. In February of 1991, Rees ended up in the hospital with kidney complications — one of the potentially fatal outcomes of an advanced eating disorder. “I was depressed, I was suicidal,” Rees recalls. “I really didn’t care if I went back to school or not.”

While she was in treatment, Rees started making art again — an activity she has enjoyed since she was a small child. “I started doing some things in my artwork that were sort of scary to see, but also sort of revealing …” Back in school, she continues, “I began doing therapeutic work in congruence with my art therapy courses and started to understand how art therapy works.” After graduating, and after working as an art therapist with chemical addictions patients, she realized something was lacking. A friend suggested she follow her own woundedness as a way of finding her calling. That’s when she decided to receive her certification as an eating disorder specialist. “This is your assignment,” she recalls. “This is what you’re supposed to do with your woundedness.”

Wound into light

Rees is another of the lucky ones: Not only did she recover — she has been free of symptoms for more than a decade — but she continues to give to others the gift of healing that comes from a place of deep understanding. She and a small group of financial backers opened Selah House two years ago, after Rees had been practicing art therapy and eating disorder counseling for 10 years. Rees, who is also a practicing artist, considers art therapy a critical component of the treatment program at Selah.

Art therapy works, Rees explains, because it “bypasses the intellectual side and gets straight to the emotional side [the patient has] repressed or denied.” Rees, who has shoulder-length blond hair and deep-set eyes that carry both wisdom and vestiges of her painful past, has an authoritative but receptive presence. “When you can’t identify what you’re feeling, the therapist doesn’t know where to take you,” she asserts.

Eating disorders are not new, but they are persistent, suggesting an archetype of brokenness that our culture, our family systems, our sex role expectations still seem to engender. While there is no easy cure, there is treatment and healing and, for those who seek and receive help, the long-term prognosis is good.

Food, of course, isn’t the real issue. Food becomes a symbol, a means for control. There is no single trauma, or type of trauma, that exclusively causes a person to become anorexic or bulimic, or slip into any of the other variations of eating disorders such as compulsive dieting, distorted body image perceptions or excessive exercise — all of which can be a part of full-blown anorexia or bulimia.

We’re not a culture that celebrates inner beauty, after all, despite the talk-show rhetoric and polemics on the best-seller lists about teasing out the self-esteem of our youth. We’re a culture that, despite the incessant chatter about “it’s who you are inside that counts,” places a premium on the exterior decoration, for men as well as women. We’re still, largely, a culture of appearances.

But it’s often more complicated than this. Children, boys as well as girls, may be sexually abused by a trusted uncle, aunt, brother, family friend or even a parent. This sets up a chain of events in the psyche of the developing person: A girl who reviles her body is made aware of it in ways that make it seem unhealthy. Later, the victim of abuse may attempt to control the psychic pain of a breach of trust by controlling the very object that was violated.

What are eating disorders, clinically speaking, and how prevalent are they? Current research estimates that 1 percent of female adolescents have anorexia nervosa, loosely defined as “out of control” dieting. NIMH www.nimh.nih.gov estimates that .5 percent to 3.7 percent of all women will suffer from this condition at some point in their lives.

An individual is diagnosed with anorexia when body weight is maintained at less than 85 percent of minimally normal weight for age and height. There may be intense fears of gaining weight or becoming fat when underweight, as well as disturbances in one’s self-perceptions of body weight or shape, including denial of the life-threatening seriousness of one’s low weight. For women, low body weight due to anorexia can also result in the loss of menstrual periods.

In its darkest manifestations, the most common complications leading to death from the condition are cardiac arrest, fluid imbalance, kidney failure, electrolyte imbalance and suicide — although there are numerous other symptoms that can result, or lead a physician to diagnose the condition.

Bulimia is characterized by uncontrolled eating of large amounts of food — sometimes thousands of calories in a sitting — followed by the purging of those calories through vomiting, fasting, excessive exercise, laxatives or other means. Bulimia is usually characterized by feelings of guilt, depression and self-condemnation. The most common complications of bulimia, which can lead to death, are electrolyte imbalance, irregular heart rhythms and suicide — not to mention a whole host of other destructive symptoms, from damage to tooth enamel to intestinal problems.

“There were times [at Selah] when I was ticked off when I had to eat a hamburger or pizza,” Sarah remembers. When the issues come up now, the triggers, she asks herself, “What do I do? I want to restrict, I want to hurt my body. That’s usually when I go back to an art project.” Sarah, in her mid-20s, is following the path of Misty Rees, and attempting to help others find healing in the same way she did. Since completing her treatment at Selah, she has been working on her master’s in counseling and art therapy at a Central Indiana college.

Recovering body image

Selah House is one of a few residential treatment facilities in the Midwest for individuals with eating disorders — and the only independent facility dedicated to the treatment of eating disorders in Indiana. While outpatient therapy is also effective, severe cases will often respond more quickly in an inpatient setting.

A 45-minute drive north of Indianapolis, in Anderson, Selah House could easily be mistaken for a retreat center, spa or bed and breakfast. The house sits on a 63-acre estate, with rolling hills and a horse pasture. In addition to art therapy and body image workshops, residents’ treatment includes equine therapy, writing, dance and movement therapy as well as traditional counseling that often involves the client’s family members. While the eight-bed facility serves women, there are a number of outpatient treatment facilities in Central Indiana that also treat men .

While eating disorders are mostly publicized as afflicting women, 10 percent of documented cases are reported by men. According to a recent study published in the June 2008 issue of the Archives of Pediatric and Adolescent Medicine, roughly 3 percent of adolescent boys binge eat or purge at least once a week. But eating disorders can manifest at any age — from childhood to advanced age.

Director Misty Rees stresses the importance of treating the whole person. Her treatment approach at Selah includes a spiritual component, one that reflects her own beliefs and experiences but does not exclude any faith or the absence of one. The spiritual component is intrinsically linked to the art therapy.

Rees leads a body image workshop at Selah, which provides, as she describes, “an opportunity to address the difficult issues in a safe environment. Art is seen as something simple and playful and childlike to [the client]. Because you have an end product, it’s very good for reflection. That’s one of the reasons we continue to hang the artwork in the art room, so the women can see that they are [making progress]. The main goal of the body image workshop is for the resident to move from an eating disorder body image to a recovered body image.”

What does this process look like? “The first thing that we would do is to identify past experiences that would contribute to beliefs that they have about their body … things they have seen in magazines, things that have happened to them … they do that as a sort of free association. The next step is we have them express those images in words and visually.”

For instance, Rees might ask, “‘When you think of fat, what does it look like?’ One client said bubble wrap.” The client was given bubble wrap to adorn her symbolic body.

“Once we do that then we kind of have them get ready to write a goodbye letter to that body image. What we’re wanting them to do is acknowledge that they need to let go of what that is and redefine that. And also acknowledge the grief of the image they can’t maintain.” This could be an ideal weight or body shape.

Rees recalls one client’s memory of a rape experience. “It was in the body image workshop that she connected to that and was able to start talking about that with her therapist. This is what was done; this is what was said to me.”

Love and anger

Chaia Hazan, chaplain at Selah House, is another success story. Hazan struggled for years with eating disorders, which she also attributes to abuse issues. Yet she is quick to point out that eating disorders are not always caused by abuse. There are numerous reasons a person becomes disconnected from her body, and it becomes, then, a symbol, a separate aspect of herself that she can control, a sort of substitute for the self. Chaia’s eating disorder, nicknamed ED in the Selah lingo, “was my angel. It was everything to me. I could breathe there. It was safe; it was mine. Then the angel switched … it became a horrific monster.”

Echoing Sarah’s experience, Chaia recalls the importance of art. “To get something out of my body and onto paper made it much easier to let go. I could get it out there instead of leaving it in my body.”

A central tenet of the approach at Selah — which goes hand in hand with art therapy and other sensate therapeutic approaches — is the spiritual component of healing. “Really, to me what God represents is love,” Chaia says. While Selah House includes what are described as “biblical truths” in its treatment approach, “If you’re really walking out in love, it’s not like you have to put a doctrine on somebody.”

The other side of love is anger, an emotion that often comes out in the art therapy sessions. In one of Sarah’s images, a monster figure glares from the paper; more innocent images surround it — the letters of the alphabet, for instance — with many of the images covered by a dark scribble.

That anger is often directed towards God. In Sarah’s experience, “I needed permission not to believe [in God], and to be angry with Him. I needed permission to question.” Sarah picks up a box. Inside it, shards of broken wine glasses are wired together. The symbolism is clear: Pieces of herself, broken, have attempted reunion.

As Hazan asserts, “When you include spirituality, the likelihood of success increases exponentially.” A 1997 study published in Eating Disorders: Journal of Treatment and Prevention identified common spiritual issues of eating disorder patients: negative images or perceptions of God, feelings of spiritual unworthiness and shame, fear of abandonment by God, guilt or lack of acceptance of sexuality, reduced capacity to love and serve, difficulty surrendering and having faith, and dishonesty and deception.

In The Owl Was a Baker’s Daughter: Obesity, Anorexia Nervosa and the Repressed Feminine, Marion Woodman, a Jungian analyst, tells the stories of women who have struggled with eating disorders. Without exception, the women’s dreams and painted images serve as spirit guides towards healing. Connecting the struggle with body image as an aspect of one’s spiritual brokenness, Woodman writes, “The rational approach to obesity has proved futile for countless women. Consciously they may understand why they are driven; unconsciously their actions resist change.” Symbolically speaking, “The god demands recognition and, willingly or unwillingly, they must pay their debt to him.”

As Woodman further points out, “The acceptance or rejection of food is symbolically crucial in all religions.”

The underlying reason art making — whether visual art, dance or music — is so effective for women with eating disorders is in its symbolic value and in its sensual aspect, as a means of reconnecting body and spirit, or psyche and soma. “Genuine spiritual experience for the woman must penetrate with passion into her body, and her yielding to that power brings forth the new creation, the new attitude to her immediate environment,” Woodman writes. “The immediacy of the moment will demand her flexibility, wisdom and compassion in each daily situation.”

Those daily situations, where control is least likely to happen, offer the ongoing challenge for those who are wounded, for those in recovery.

Now that Sarah is on her own again, moving ahead with her life, the challenges to stay on track will remain: The negative voices will still need to be quieted at vulnerable moments. She’ll have her art, and her faith, to keep her going. Still seated on the floor, Sarah begins to pick up her artwork. Chaia stands up, ready to head back down the hall to her office, ready to get back to work. “Walking out of here is the next field of battle.”

Selah House
2541 North Shore Blvd.
Anderson, Ind., 46011
888-692-0505
www.selahhouse.net

Art Therapy 101

Edvard Munch’s “The Scream,” Van Gogh’s “Self-Portrait With a Bandaged Ear.” Both paintings are iconic reminders that art, whether or not it heals, offers a means of self-expression that reaches beyond the power of words.

Artists often speak to the creative process as something moving within or through them, but not something they consciously direct. As Howard McConeghey writes in Art and Soul (2003), “the image-making power of the autonomous psyche is not the work of human will and reason.”

This, more than any other notion, is at the crux of why art making is a trusted tool in many therapeutic approaches.

In one of the classic texts of art therapy, Introduction to Art Therapy: Faith in the Product, Bruce Moon writes, “The task of the art therapist is to attend, to serve as midwife to the birth of the artwork.” That artwork symbolizes a sort of reconnection to the soul, often darkened by grief, trauma, or other psychological stains.

Liza Hyatt is an Indianapolis-based artist and art therapist who sees clients coming from a diversity of emotional stations, not all of them dark ones. Hyatt, a national board certified art therapist and licensed mental health counselor in Indiana, worked as an art therapist with clients at the Julian Center, a shelter and counseling center for female victims of domestic abuse, for 13 years. “Art therapy is really effective with people who are dealing with trauma like sexual abuse,” Hyatt says.

Distinguishing art therapy from traditional counseling, Hyatt explains, “In talk therapy you can talk around a lot of stuff. Things come out from the subconscious pretty fluidly through art.”

What exactly is art therapy? According to the Web site of the American Art Therapy Association, a group representing roughly 5,000 member therapists and state and regional chapters, art therapy is “a mental health profession that uses the creative process of art making to improve and enhance the physical mental and emotional well-being of individuals of all ages.” Further, “It is based on the belief that the creative process involved in artistic self-expression helps people to resolve conflicts and problems, develop interpersonal skills, manage behavior, reduce stress, increase self-esteem and self-awareness, and achieve insight.”

“Because art is an image language, you can transform those images,” Hyatt says.

With eating disorders, for instance, “It’s pretty much recognized that art therapy is a crucial component to the treatment of eating disorders,” says Hyatt. In addition to Selah House in Anderson, Ind., many hospitals and other psychiatric institutions, as well as individual therapists, offer art therapy as part of an overall treatment program. “Art is a physical medium,” Hyatt explains. Individuals suffering from eating disorders are characteristically rigid. Their world is very small and limited as a result of the disease. “Art asks you to expand in broader and broader circles.”

In addition to seeing individual clients, Hyatt now works with the Charis Center for Eating Disorders, affiliated with Clarian; and is also working with cancer patients at IU Hospital to create a mosaic, as a sort of community-based art therapy program. “I’ve found that mosaics are a great metaphor for healing, for putting our lives back together.”

Art therapy, then, is universal. Anyone can benefit from the soulful explorations, the connection with the sensual, that art making offers. “In my private practice I like to work with people who are going through a creative transformation,” Hyatt says. “They’re opening to their spiritual selves.”

To contact Hyatt, visit her Web site at www.lizahyatt.com.