Original Articles

The use of art therapy for diabetics Sheila Knight BA DipATArt Therapist, Fern Tower Adolescent Unit, 1 Dundonald Road, Glasgow GI2 9LJ

Abstract Diabetes may bring with it many emotional problems about which many

patients may not be able to easily express their feelings. This has been recognised by physicians and some experiments in the use of psychotherapy

have been tried. Art therapy is used in the treatment of mental handicap and mental illness and, as a diabetic, I have successfully used art to help me to cope with my condition. Given appropriate facilities such as a diabetes day centre, art therapy could be

offered to patients as another means of coping with the problems of their diabetes. The effectiveness of art therapy needs to be properly evaluated.

Introduction I have been an insulin-dependent-dia-

betic for 17 years, an artist for about 10 years and an art therapist for two. I have drawn upon my own experience of dia- betes and that of others to describe the emotional problems that may be experi- enced by diabetics.

Art has helped me cope with these problems and could do so for others. Art therapy is already used in a number of centres in the treatment of the mentally ill and mentally handicapped and I think that there is a role for it in the treatment of diabetes as well as other physical dis- orders.

Why diabetics may have emotional problems

We are all responsible, to a certain degree, for our own health. Within limits we can choose to smoke or not, to drink or not, to exercise, and choose what to eat. Some people without any other con- dition find this responsibility a burden! The responsibilities faced by the diabetic involving decisions about insulin treat- ment and many other aspects of care is much greater.

Diabetes is a hidden disease. Most dia- betics, particularly young insulin treated ones, may look extremely healthy and will not receive the concessions and sym- pathy that are usually made for sick people. ill some instances the miper- ceptible quality of diabetes may lead the diabetic to further suppression of any signs of the disease, for example in failing to admit that he or she is not coping with the responsibility of self-care.

Treatment for diabetes may bring emo- tional problems. Most people find injec- tions frightening and the diabetic has to overcome his or her own fear and also cope with the fear and ignorance of others. Injections are open to misinter-

pretation with the possible association of addiction to heroin. To avoid the risk of misplaced moral condemnation, the diabetic may tend to hide the disease and its treatment.

Food is part of the treatment for dia- betes and it becomes like a medicine. A diabetic does not have the freedom to eat on impulse, cannot indulge feelings of hunger and has to eat measured amounts at specific times even when having no appetite. The desire for food is a basic human urge forming part of the need to be nurtured and mothered. Restriction of that need will have some psychological effect. Furthermore the need to know when and what you will be eating can cause social problems and embarrass- ment to the diabetic and his or her friends.

Hypoglycaemia can also cause social problems. When hypoglycaemic, the dia- betic finds it almost impossible to explain to someone who does not understand what is happening or that he or she needs food or drink quickly. Hypoglycaemic behaviour can easily be mistaken for drunkenness.

Visiting diabetic clinics, eye clinics, contact lens clinics, GPs, chemists, and others is time consuming and can become expensive. Having time off work to do so can be very difficult and in times of high unemployment can be a severe threat to job security. The careful planning of in- jections, diet, exercise, visits to the clinic OF GP not only affects the patient but also friends and relations. In some cases families have found it very difficult to accept these demands (Ref I ) . For the patient the desire not to create worry or concern for friends and relations and the desire not to be a nuisance may cause additional strain.

Lastly, the inevitability and lifelong nature of the disease, as with other chronic diseases, can be psychologically tiring. The constant balancing act to

maintain a steady blood glucose level and the fear of long term complications all have a psychological toll.

What can be done to tackle this problem?

The psychological problems of dia- betes and the general inadequacy of the traditional health service provision in meeting this aspect of diabetes care have been recognised by many physicians (Refs 1-5). Some attempts have been made to offer help (Refs 6-9), for ex- ample, there is some evidence that group psychotherapy has helped diabetics to cope with treatment and the demands on their lives.

Other more informal ways of tackling the psychological problems of diabetes include self-help groups, the BDA, young diabetic groups, and counselling by the diabetes nurse.

One method which has not been tried on any organised or research basis is the use of art therapy.

What is art therapy? In general we rely on verbal or written

exchanges to communicate with each other, but words can fail us especially when we are trying to express feelings and emotions or things that are too frighten- ing to talk about. Not everyone has a good command of their language. Doc- tors are usually very articulate and this may sometimes make patients feel even more inarticulate and inhibited when trying to express their emotions. Children, for example, may not be able to find the words to express their ideas, and people with mental or physical handicaps may be unable to speak or understand the system of language. Art can be an aid to verbal and written communication.

In many ways art therapy is similar to psychotherapy. It can take the form of individual sessions or group therapy. Some peopie may feel more confident m a one-to-one relationship while others may benefit from the companionship of being with a group of people who share prob- lems. One advantage of art therapy over psychotherapy is the fact that if people can physically do something it often helps to ‘break the ice’ and make communica- tion easier. The ability to ‘do something’ is not as frightening as the eye to eye contact encountered in psychotherapy groups. Art therapy allows a relationship

226 Practical Diabetes SeptemberlOctober 1987 Vol4 No 5

Original Articles The use of art therapy for diabetics

to develop between people as well as c Figure 1 between a person and his or her work. This can be continued priv- atelY at home and provide a for emotions, when there is no one avail- able to share confidences.

The fact that art is tangible means that the artist can solidify an abstract emotion and so observe it from a distance and be in control of it. There is a choice tg destroy, keep safe, or exhibit artworks. Artworks that are kept can provide a visual diary of past feelings and emotions and enable the observation of changes in these experiences over a period of time.

The fact that one 'does' art means that it is a creative experience in situations that could be passive or negative, enabl- ing people to develop confidence and self-esteem. The therapist encourages issues such as self-confidence, coping abilities and emotional growth by building a trusting relationship and by observing and discussing the artwork with the patient. The process of produc- ing artwork and the ideas behind it are more important than the finished article.

Personal use of art as therapy I have only been involved with art

therapy for two years but have always had an interest in art and have completed an art education and produced my own artwork. Figures 1-4 are examples of the many drawings I have made for myself over the years. They were not drawn with the intention of display but were a personal of coping with the emotional problems caused by diabetes. The fact that I now able to display them publicly must be some measure of success for using art in this way. The captions explain the drawings.

These drawings were created immediately after an emotional experi- ence concerning diabetes. I could only produce these because I was relaxed and used to the art medium. I was not able'to put my feelings about these experiences down in words but now that I have used art to communicate these feelings, I am more able to articulate my experiences.

Sweets come in many different forms and have interesting names like Turkish Delight and Whisper. The names alone encourage curiosity about their content.

Poor diabetic control leads to health complications; the loss of eyesight could be the price paid for eating these sweets. This drawing shows the dificulty of

being strong all the time and having to ignore offers of food and messages from advertisements which all try to seduce you.

Figure 2 //lustrates the refusal of food and the need to state the fact that I am different from other people. /f / do not explain that / am diabetic it might be wUmed that / choose to refuse the Offer Of food, with the imp/iCatiOn Of rebuffing the

offer of friendship.

My artwork has enabled me to: (a) explore emotions that I felt unable

to share with anyone; 0) express and acknowledge feelings

when there was no one available to confide in;

(c) reflect on previous emotions and consider how they influenced my life, work and actions;

(d) see if my feelings and emotions about diabetes were acceptable and understandable to others;

(e) share my emotions with others and so strengthen my confidence and feelings of self-worth.

'racticd Diabetes September/Oct&r 1987 Yo14 No 5 227

Original Articles

Art therapy in the treatment of diabetes

De Leeuw et a1 (Ref 7) describe the chance discovery of an adolescent’s drawing that expressed his anxiety about his diabetes. This young man and I have both chosen art as a form of communica- tion and as a way of coping with the problems of diabetes, and many other patients may be able to benefit from a similar use.

However there are difficulties involved in beginning art therapy. The terms art therapy, or psychotherapy. may diminish patients’ confidence even further because of the suggestion of mental illness and in- ability to cope. The introduction of such techniques has therefore to be handled sensitively and carefully.

Artwork, if it is to be therapeutic, can not be scheduled or produced on demand. An art therapist usually requires an art room where art equipment and art works can be left undisturbed. The atmosphere of an art room is important; it must be free from interruptions and equipment and water must be readily available. The suitability of traditional diabetic clinics for many aspects of diabetic care, such as education, has been questioned and the traditional clinic would undoubtedly not be suitable for art therapy. However, experiments in the use of day centres have been reported (Ref 10) arid art therapy could be more easily included with this type of organisation.

In my work with the mentally handi- capped I prefer to see patients for indi- vidual sessions when they are first referred and then consider who would benefit from group work. This choice must be flexible and I generally try to suit the patients’ wishes and let them choose how they work. In western society most people feel that they are unable to draw and so have fears and barriers towards the use of art. However, lack of drawing ability is less threatening than lack of language ability and patients generally relax when it is explained that drawing ability is not important. A few simple art- based games often help.

Ideally an art room should have a ‘drop-in’ facility as well as an area for scheduled work. Where I work, people who are not referred to the department often drop in for a coffee and a chat on an informal basis. I believe this is because they are aware that they will be listened to and yet, as there is a lot of other activity, they do not feel as if too much attention will be focussed on them. This is a tech-

Figure 3 Waking up in a hospital after a

hypoglycaemic experience. I had experienced a ’hypo’ while asleep so

that my last memory was of going safely to bed. When I awoke I was in

a strange place with no clothes on and with strangers staring at me.

nique we all use, from discussion of business deals on the golf course to personal conversations at the hair- dressers.

Most psychiatric and mentally handi- capped patients attend art therapy for an assessment period of approximately six weeks and then often continue to attend art therapy sessions for months or even years afterwards. Most aiabetics have a normal mental state and should be able to adapt to the use of art therapy much more quickly than this. Suitable patients could be offered help initially and then encour- aged to continue on their own or in self- help groups, with the art therapist avail- able for consultation if needed.

Conclusions Art therapy is used effectively in the

treatment of the mentally ill and mentally handicapped and has helped me to cope with, and adjust to, the emotional pro- blems caused by diabetes. Unlike psycho- therapy, no-one has ever tried art therapy on an organised basis in the treatment of diabetes or tried to evaluate its effect- iveness. It is high time for its effectiveness to be evaluated.

The use of art therdpv for diabetics

Figure 4 Represents the intellectual headache of trying to control diabetes and get

my body to remain within the normal blood glucose levels. The

electricity wires represent the normal glucose levels and the small figure is my brain trying to control my body.

Acknowledgement I should like to thank Dr Ray Jones of

Department of Community Medicine, University of Glasgow for editing and typing the manuscript.

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