Community Partner: Ray Mathew-Santhosham

The first time I ever made a collage in a therapeutic setting was when I was in a pain rehabilitation program. It was a pediatric program at Cleveland Clinic, very holistic and just aimed at trying to get kids who were struggling with chronic conditions back to functionality. A lot of us hadn't gone to school in months, and that was the case for me as well. And basically, we were using collage to make vision boards of what it would be like to go back to school and how we can imagine our lives as people who are functional with their disability. That just sparked me realizing that I loved collaging.

As I was facing my own disability, I realized that I couldn't draw or paint like I used to because of damage to my hands. When I learned collage in rehab, I realized how accessible and meaningful it was, and my therapist recognized that I have artistic capabilities and how much I enjoy art in general. So she was like, "Why don't you use collaging as a way to get out some of those really upsetting cognitions, just to externalize that?” So I started making collages for myself first to deal with my own trauma. And then just because I am a community-minded person, I thought, what if I invite my friends to do it with me as a way for us to bond? Also, just to save time, because I don't have time for self-care and hanging out with friends.

Once I started doing that, I realized, wow, this functions even better with a group, especially for my other queer friends. We were building amazing discussion and connection, sharing our stories together. And then it came time for me to pick a thesis subject, and my mentor told me, "Tell me what you're interested in." I said, "Well, personally, I love art. And academically, professionally, I care a lot about trauma research and finding integrative and new therapies to help people who find regular one-on-one talk therapy abrasive at first.” I was trying to figure out a stepping stone to help treatment be more accessible. And my mentor was like, "Well, you collage. Why don't you come up with a collaging therapy?" And I was like, "Wow, I didn't know I could combine the two favorite things in my life."

So that's where it all started. And then I just developed a protocol and started testing it with my friends—this one specifically focused for queer people because historically, the therapeutic community has actively discriminated against the queer population, which makes it hard for us to access therapy. Even when we can access therapy, the LGBTQ+ community has very low retention rates and are at risk for a whole myriad of disorders and problematic behaviors without a lack of treatment.

This was specifically aimed at the queer community to allow them to realize that healing and safety can exist in different forms, and to act as a community-building aspect for queer people so they can come together over the purpose of healing rather than partying or drinking. 

And there's not a lot of research about adults using art therapy, at least in the social work field. Most of it is around pediatrics and working with children. So I was really excited for the opportunity of using collaging, a thing from art therapy which is traditionally used for children, to allow people to connect with their inner child and come back to those childhood memories. And obviously, I'm excited to get research out there that shows that art is effective in adults, too.

It's assumed that adults lose their creativity. Which in a way is true, but I don't think we have to just sit back and accept that, especially when there's an opportunity for healing within that.

A lot of the intervention is based around reprocessing. So taking those traumatic memories or maladaptive coping mechanisms or thought processes and putting them out there, so that you can play with them and move them around to see what you can do, and that is innately creative— being able to think in a way that is different than maybe what you have in the past. So it teaches these skills that are just important throughout life and if you choose to further therapy. Because a lot of times people enter the therapy setting and they're like, "Well, I've never talked about myself before." And it's very uncomfortable.

When I did the first iteration of the study, a lot of the feedback that I heard was similar: that they were remembering that they could be creative like a child, and they could be creative without thinking, oh, I have to make it look perfect. That they could make mistakes and then rebound from that. So that was definitely one benefit for the participants as well as giving them a coping tool.

One of the participants stated that before the intervention, if she would be sad or something triggered her, she would just turn on some music and lay in sadness, which is understandable. We've all been there. But she said after the study, she's been having this inkling when she's feeling sad to draw or doodle, or express it in some way. And when she told me that, I was like, "That is exactly what I wanted to happen. This is perfect."

And all of the participants in my study also stated that they wanted resources to reach out to get more therapy afterwards, which is incredibly amazing to hear, especially since all five participants in the beginning of the intervention said that they'd given up on therapy. It was able to create some huge change in terms of their confidence with their coping skills. A lot of them are working on just being able to express their life story, which they had never done before. And having a clear space makes it so much safer because we're always making little jokes with each other, quipping like, "Oh, that happened to me too." There's that camaraderie in the shared experience that lets people ease into the idea of, oh, I can share about myself openly.

And a lot of it is psycho-education based as well. I'm teaching them about how trauma manifests in their body. They can understand how their reactions are related to what happened in their childhood, which will hopefully make them feel a bit safer when they enter that therapeutic space later on.

Exactly. They have words. They know that other people are doing the same thing that they're doing and still struggling with it. There were lots of tears. There were lots of emotions when we were sitting as a group and talking about these things, but part of the psycho-education is being like, "This is how we all react differently." And I asked them to focus on their body sensations. Some of us started crying, some of us got sweaty, some of us got shaky, and all of that can help them strengthen their ability to stay with therapy when they start to go into that more seriously because they can put a word to what they're feeling. Now they can say, "I'm starting to feel sweaty," or, "I'm starting to feel my heart rate rise." And now they know why that's happening, because there's a memory being triggered.

I also was very adamant about providing other resources, because the point of social work is to just connect people with whatever resources they might need, specifically queer therapists. There aren't a lot of them in the area, but we are fortunate as a city with a lot of queer supports. So that was a huge thing; the participants realized, I don't just have to go with whatever's around here, I can find a therapist who might be a person of color or disabled, or queer. So this whole intervention was just to open up people's eyes to what kind of treatments that they can get. I know some of them might choose to just stick with what they've gained, but some of them with maybe more complex issues might want to get back into therapy. I think either way, if we're equipping people with tools, that's what's important.

One of the reasons I'm doing this is that there's not a study like this so far. For my literature review, and when I was coming up with my protocol, I was looking mostly at research regarding art therapy used for adolescents recovering from sexual assault. So I took a lot of their framework from that, as well as some other studies done with refugees. A lot of them are women and a lot of them are sexual assault-related. There is not a specific focus in the research so far on queer people or specifically overarching childhood trauma. I think that because of some of the psychodynamic theories that have been embedded in social work, for a while people were just like, "Yeah, if we're going to use art, let's talk about sexual abuse."

But I think what's really cool about this medium and this protocol that's being designed is like, you can address your queer trauma. You can address your sexual trauma. You can address your family trauma. We have some people who were specifically working on religious trauma. And we had some people who were like, "I have trauma with friends because of this.” So it opens the door for a lot for people, this specific protocol. But it did stem from some work being done specifically with adolescent women having experienced sexual assault, which in the LGBTQ+ community is highly prevalent.

Yes. The occurrence of adverse childhood experiences are also incredibly high in the LGBTQ+ population. One of the eligibility aspects of the study is that you have to have more than one ACES, but that's just to open up the eligibility. I'm concerned that statistics are showing that the adult LGBTQ+ population in America is experiencing four plus adverse childhood experiences at a rate of 86 percent, whereas the general population has a rate of 14 percent for that. The ACES test is a quiz essentially, and it is a groundwork in this.

That has been monumental in the research field, just to be able to measure that and track how people's childhood experiences are leading to their health outcomes. It's one of the reasons this study is super important, because the LGBTQ+ community experiences a lot more abuse in many different areas, whether that's sexual abuse, family abuse, verbal abuse, or even just having a history with mental health concerns in families. At the same time, this community is very under-served. So this is specifically aimed at addressing their childhood trauma in this young adult phase, which we call emerging adulthood, when young people are most equipped to deal with their childhood trauma.

Adolescence is also a good time. But at that time, people are going through a lot of different things, and especially queer people. Queer people have something they now call in research a secondary adolescence. It happens in this early-twenties stage, when a lot of people have just come out, left home and they're re-figuring out their identity. And a lot of them experience those same things that you might experience in adolescence where you're figuring out how you identify sexually, how you want to express that, who you want to be with. And then being open with your family and your friends about your identity.

So this period that I'm focusing on, from 18 to 28 years old, is very critical in terms of being able to dive into their trauma and think more deeply and creatively about it. They have more tools. Oftentimes they have left that abusive situation now that they're in adulthood and it's coinciding with their own identity development. So it's allowing them to embed some of these more healthy thought processes and these strength-based perspectives while developing their own identity.

Through Tracie's help, I was able to locate my thesis study here. Because social work is building its momentum as a research college, and because this is art based, I thought this would be a good, neutral location for people to come to do their art therapy. The [February] workshop was combined with my thesis work.

In the first session, I asked the participants to think of a positive memory related to their trauma and a negative memory related to their trauma. They were like, "Positive memory. What do you mean? It's my trauma." And we discussed that as the bridge point for understanding that we are expanding our narratives. We're not just focusing on the negative.

So for one example from a practice group I did with friends, they said one of their memories was their dad saying that, "Lesbians are only lesbians because they're ugly and can't date a man." I also told them, "We're not trying to find the worst thing that ever happened to you. I'm going to leave that for a one-on-one professional because this is a vulnerable setting, being in a group. So let's pick something in the middle that hurt you but doesn't cause an extreme reaction." So they picked that negative memory. Obviously, very formative for a child who's a lesbian to hear.

And then the positive memory would be that first time that person went to a school dance with a same-sex partner. So expanding their story to realize, I gained strength from being able to overcome that. Even if they look different for everybody, it's important to identify those moments where you did overcome and integrate those into a story. So the first session I explain a lot of the psycho-education aspects, what we're going to be doing, and then they start to identify their memories. And from there, they will try to identify core beliefs that came from these memories.

That's giving them a little avenue into their mind and the way that they're thinking, and how that's expressed in their narrative, which also helps with creating a visual story. And with collage, you can embed a lot of words in that. So I encourage them to put the words of their core belief in their collages. A lot of the core beliefs can be like, I am worthless. The world is not safe for me. I have to protect myself. Or conversely, I can trust in others to hear my story, to listen to me. And the goal is that hopefully ,over the course of four sessions, they develop more and more positive core beliefs, which is what we did see happening. Especially because that group aspect was allowing them to be like, "Wow, you were really strong in that moment. I can't believe your parents did that to you. And then you just went straight to school. That's crazy." These participants are getting feedback and support and encouragement from their peers, and hopefully then giving them counter-arguments to the “lesbians are ugly” arguments they've heard in the past. So there's a lot of dialogue there.

After that first initial session, we're mostly just working with magazines, picking out pictures, collaging. I do the annoying bit of poking at them and being like, "What are you working on right now? What does that mean to you?" And then I make them share it out loud. And I explained that to them in the beginning, identified goals for the intervention. I was like, "You have identified that you want to get better at talking about it, so we're going to practice this in a safe space.” Participants said that they appreciated the naturalistic aspect. Now they're practicing what it's like to talk about vulnerable things with their friends.

The rest of the sessions, we just talk through what we're wanting to represent and how we're representing that. A lot of times, participants started with wanting to separate the negative and positive on different sides of their canvas. But then as the sessions grew further, you saw literally the two sides come together, to be an enmeshing of, these are some strengths that I gained, these are some things that hurt me, but this is how I'm going to move forward from that.

One participant I know one was culture-based, and she was talking about how her Indian and South Asian culture had both strengthened her and hurt her. And then you saw there was a beautiful side of the South Asian culture and a scary side of the culture, and you saw that come together by the end of the piece. And what's really beautiful is, everyone's piece looks incredibly different, but the elements of their story and their reflection of that is coming together.

I think it was the Night at the Museum event that the OUAB was doing for all [of Ohio State’s] art students, that one of my participants entered the collage they made in our workshop to the show. I went to the show not knowing that and I was with my friend. She goes, "This looks like your collage." And then I was like, "It looks like my collages because I taught them my method." And they wrote a little description, literally describing what they had learned from my protocol, and I cried.

They're able to see their work as something that is a tangible reflection of their growth. A lot of the participants hung [their collages] up on their walls as a symbol of overcoming. That's what I gained when I started collaging. It's really cool that other people are latching onto that and really enjoying it. And as a medium, it's super accessible to do outside a therapeutic setting, as well as something that can be replicated in other programs quite easily.

I also believe that there's an important social justice aspect underlying that. If we're building a community, we should strengthen our resourcefulness. Being able to find coping and healing mechanisms that are actually accessible and able to be embedded in people's lives. And collaging is important for not only that physical accessibility of materials, but also cognitive, physical, and medical accommodations as well. We want a medium that can be effective for people who might have OCD or perfectionist disorders that make them feel like they can't draw or that it's too stressful. I know I get so stressed out if I try to draw or anything, but I love collaging because it's already there for you. You just have to do more of the conceptual work and that opens the door to a lot of healing.

Since I was working on my thesis and there was a very strict time constraint, I had mostly advertised with OSU student organizations because they were the most responsive. Because that is a specific educational background, I wanted to branch out our diversity, reaching out to more centralized and local queer organizations that serve all types of people, whether educated, working, older, younger. I just wanted to be a little bit more diverse in terms of severity of trauma experience, as well as educational background. 

This time around, I've reached out to Mozaic Ohio, an organization specifically focused on grassroots organizing with people of color. And then I've also reached out to Kaleidoscope, which is focused more the younger end of my skills. I'm trying to get more older folks involved as well, more into that [late twenties] range. (Editor's note: those who are interested and fit the criteria can contact Mathew-Santhosham directly via email.)

We definitely saw a statistically significant reduction in traumatic stress symptoms, as well as an increase in problem-focused coping mechanisms. There were trends in overall increased coping skills and overall increased emotional regulation. But there wasn't enough data to create a strong statistical relationship. So one of the goals of doing this, another iteration of the study, is to just get more data to bolster the trends that we're already seeing happen.

I'm specifically using mixed methods. so I have interviews before and after the intervention with participants who are willing to give me that extra time to share in a one-on-one session how they actually felt. I measure their anxiety every week and their satisfaction every week, but I want to hear word-for-word quotes. And that is something that is specific to social work: we tend to love mixed methods and hearing people's actual voice. So that is helpful in understanding what kind of impact is being made.

I entitled the intervention Puzzling Pictures. It used to be Reweaving Memories but I renamed it because in one of our interviews, a participant said, "I liked it because it felt like I was puzzling together my story of my life."