Verified by 
At last summer's conference, I had the good fortune to meet this column's guest blogger, Dana Keeton, MS, ATR-BC. Ms. Keeton works with civilly committed male sex offenders in a residential treatment facility. In addition to providing individual and group art therapy services, she has been developing the facility’s first Rehab Department, which provides art therapy, music therapy and recreation therapy services its residents. It was only natural for Ms. Keeton to write a guest post about her own experiences with sex offenders. The difficulty with working with marginal, and oftentimes disturbing and misunderstood population is clearly illustrated through her case with Bob, a resident of this program.
Ultimately this case, first presented by Ms. Keeton at the American Art Therapy Association national conference this past July, reveals that while art therapy can be used to mitigate symptoms, working with this population is not only difficult, but often times results may not be readily apparent. Keeton’s client continued to demonstrate deception and manipulation—it was through the art that he could learn to express any depth of honesty, vulnerability and even self-reflection. The client may never be ‘cured’, but through art therapy, as Keeton demonstrates, her client could lower his own risk of re-offending.
Please note: While the author was unable to include her client’s art, she included her own pieces that were responses to her experiences. A section is included following the case vignette that provides statements for each piece.
Peeling Away the Layers: Art Therapy with a Male Sex Offender
By Dana Keeton, MS, ATR-BC
When I first began providing art therapy services at a locked treatment facility for civilly committed male sex offenders I approached the work with a number of questions. What are the treatment goals? Can the clients change their deviant sexual behavior? Will I have empathy and be able to develop a therapeutic rapport with clients who have committed violent sexual crimes?
The locked treatment facility is on the grounds of a state hospital populated by men who have committed multiple sexual offenses. Such people are determined by the court system to be a Sexually Violent Person, and ordered to the residential facility for an indeterminate amount of time directly after their prison term has ended. Once committed, their length of stay varies and is typically measured in years. A prison mentality pervades this population.
Initially, I worked with clients in individual sessions. I approached these first sessions like I would with any other clients--listening and observing, conducting assessments, and building a therapeutic rapport.
I learned that similar to clients I had worked with in other residential facilities, their histories included damaging stories of abuse and neglect, substance disorders, mental illness, and often a lifetime of institutionalization. Many of the clients were victims before they became abusers. Many more had antisocial, narcissistic, histrionic, or borderline personality disorders, along with paraphilias and mood disorders. I soon realized that deceit and manipulation were prevalent among these men.
Dynamic risk vs protective factors—recidivism or not recidivism?
As my work at the facility evolved I learned that the non-verbal expression inherent in art therapy fits well with a population that is prone to deceit, and who struggle with identifying and expressing emotions. As I became familiar with it, my therapeutic approach quickly became grounded in the facility’s treatment philosophy, focusing primarily on the elements that affect recidivism: an increase of dynamic risk factors and lack of protective factors (de Vries Robbé et al., 2015).
Dynamic risk factors are individual characteristics that are associated with instigating recidivism, including: sexual preoccupation; deviant sexual interest; emotional congruence with children; lack of emotionally intimate relationships with adults; poor cognitive problem-solving such as ruminating; resistance to rules and supervision; negative social influences; hostility toward women; and dysfunctional coping.
Protective factors are “features of a person that lowers the risk of reoffending” (de Vries Robbé et al, p. 18, 2015). Protective factors include: healthy sexual interests; capacity for emotional intimacy; goal-directed living; problem solving; employment or constructive leisure activities; sobriety; and a hopeful, and motivated attitude.
Art therapy with sex offenders may address risk factors, while supporting and enhancing protective factors, sometimes simultaneously. For example, its understood that art therapy may be used to augment problem solving. By doing so, it mitigates poor cognitive problem solving, which is considered a risk factor, while simultaneously enhancing constructive problem solving, considered a protective factor.
When faced with a blank page and asked to draw, my clients will often complain ‘I can’t. I don’t know how to do it.’ Yet, as I support and encourage them to use the art making process to explore their problems, simultaneously learning how to solve different problems the very act of making art may conjure, confidence is gained.
A resident at the facility known for his angry outbursts and inability to follow rules interacted poorly with others and exhibited distracting behaviors. However, when I began working with him in art therapy he demonstrated a propensity to address complicated tasks through creating numerous three-dimensional multi-media collages. With each resourceful solution during art therapy he learned to find solutions through a healthier, less violent way while simultaneously cultivating an emotional and healthier connection with the art therapist—he mitigated dynamic risk factors while developing yet another protective factor.
What about Bob?
Bob (pseudonym) was someone else I worked with who presented many dynamic risk factors, offset by only one protective factor. At the time his primary therapist referred him to art therapy he presented risk factors that corresponded with grievance/hostility, resistance to rules and supervision, and dysfunctional coping.
Bob’s resistance to treatment carried through to our art therapy sessions. He attempted to control each session with extended angry rants about numerous perceived injustices. The list of grievances matched the depth of his anger.
Although there were multiple clinical issues to tackle, I initially focused on using art to provide Bob with a safer outlet for his anger.
When I first met him he proudly showed me detailed pencil drawings of famous people and carefully crafted landscapes, presenting himself as a self-confident artist. Despite this, during our first art therapy session he claimed ‘I can’t draw from my head. I can’t draw without having a picture in front of me.’
Eventually, his defenses broke down, and Bob began engaging in the art during session. A couple of months into our work together he disclosed a past crime that he hadn’t talked about previously; this proved pivotal to his treatment. Bob was able to use the art to express difficult feelings he was unable to express verbally.
As he continued to process the emotional fallout from his disclosure, Bob deepened his engagement with the art, using it as a mechanism for healthy problem solving—he learned to process and express his emotions productively, rather than through angry outbursts. Thus, protective factors were developed-- good problem solving and the capacity for emotional intimacy.
Bob’s art became a vehicle for expressing the very emotions he had been avoiding for years, while communicating secrets he continued to hold despite his increased engagement in treatment. He vacillated between creating abstract paintings that expressed his feelings during the session, and compartmentalized, concrete paintings and drawings he created on his own time. A number of these paintings and drawings were later revealed to contain hidden imagery that expressed the transition he experienced from the misplaced love he felt for one of his victims to the more acceptable affection he developed towards a peer.
The progress he demonstrated in art therapy paralleled the progress he made in other areas of his treatment. He soon shared and processed the hidden meaning and secrets in his paintings and drawings with his primary therapist and in his treatment groups—they became visual records of his treatment milestones.
Over time, Bob’s risk factors have minimized dramatically, with some no longer present. In direct contrast to when we began working together, he now exhibits all of the protective factors, as well as the ego strength to create art and, in turn, enjoy it.
My Response thru Art
Fig 1-Response Collage is a multimedia piece I made in direct response to my work with Bob. I chose materials that echo some of the multilayer, patterned paintings he created, while also using some of my favorite art materials to represent myself in the therapeutic process.
Fig 2-Self-care collage is multimedia collage during the early stages of my work with the client when the countertransference was quite strong, and I was exploring how to manage the intensity of his disclosures about his offenses.
Fig 3 & 4- Searching for a Path and Untitled were created more recently. The digital photographs are metaphors for my work with sex offenders, challenges with countertransference and navigating the therapeutic process with such a challenging population. Photography is my primary medium. One of my key forms of self-care is exploring the natural environment with my camera and inevitably finding metaphoric connections with my art therapy work.
Reference
De Vries Robbé, M., Mann, R.E., Maruna, S., and Thornton, D. (2014). An exploration of protective factors supporting desistance from sexual offending. Sexual Abuse: A Journal of Research and Treatment (Online pub.) 1-18. DOI: 10.1177/1079063214547582
