Personal Background

When I was a child, I had difficulty speaking out loud. In essence, I lost my voice. I remember only parts of that period. Only during the first year of my doctoral program did I remember that I did not speak as a child. My professor, Dr. Mitchell Kossak, had asked us to create the entrance to our home; I started painting a child with something covering her throat, unable to speak (Figure 1). Suddenly, long-forgotten memories from my childhood resurfaced for the first time. I zoomed into the little girl with the wounded throat, and this wound emerged. I called this painting “The Wounded Artist.” I decided to delve into a creative process and paint my emotions to reconnect to the emotions that were part of my world. The painting in Figure 2 portrays my throat as hurting because I want to speak on behalf of the little girl who could not do so. The throat is sore and hurting because it reflects the emotional difficulty that a painful experience caused. It represents my struggle.

Figure 1 - “The Wounded Artist.”

Figure 2 - “The Sore Throat.”

During this time of remembering my past, creating art was essential to reliving my emotional state when I was a little girl. It was not an easy process, but art helped revive my memories and emotions.

This research aims to help professionals and parents become more aware of the SM disorder, the unique ways of communicating within it, and methods of working with children with SM so they can begin understanding the mystery involved in the journey toward communicating.

Research Design

This study combined art-based and phenomenological qualitative inquiry. Kossak (2013) defined art-based inquiry as “the use of artistic process, and the actual making of artistic expressions in all the different forms of art, as a primary mode of understanding and examining experience by therapist, client, researcher and research participants” (p. 22). According to Brinkmann and Kavale (2015), phenomenology is a method to describe and observe—rather than analyze—the data as precisely and completely as possible. This study’s methodology enabled me to understand the participants’ lived experiences. According to Moustakas (1994), phenomenology is a method of gathering knowledge of the experience by relying on “intuitive and a priori sources of knowledge and judgment” (p. 58). This method focuses directly on people’s experiences, self-evidence, and inner perceptions to understand a phenomenon.

Participants

The participants were recruited through an advertisement on Facebook inviting participation in an art-based intervention for teachers who have a child with SM in their classroom. Advertisements were also published on a WhatsApp Israeli expressive arts group and my Facebook page. Recruitment was closed after 1 week when sufficient inquiries were received to meet the study’s requirements.

The final sample of participants (see Table 1) were six teachers who had a child diagnosed with SM in their class and seven expressive art therapists (six art therapists and one drama therapist), all with teaching certificates in Israel. Participants were randomly assigned into two groups—one of six participants and the other group of seven—to keep the groups small. The uneven number resulted from the researcher’s decision to accommodate a 13th participant who was initially unsure whether they could commit to the research study but expressed significant interest and ultimately committed to it.

Procedure

The Lesley University IRB approved this study (approval number 20/21-005), and all participants signed informed consent forms. The research consisted of a 3-hour virtual workshop comprising two 90-minute meetings and a 30-minute follow-up. As the primary researcher, I conducted all workshops. The first two meetings were held 1 week apart, and the third (follow-up) session was held 2 weeks after the second meeting. All meetings were held on Zoom due to the COVID-19 pandemic and social distancing restrictions. The Zoom software provided a unique password shared only with the participants to keep the data confidential. All the Zoom meetings were recorded. All the participants completed the entire program.

Bias

Although I received valuable information from most participants, I had difficulty communicating with some due to technical problems with the Zoom software. This limitation may have affected the overall communication in the research. For example, participants said they feared missing important information due to Internet problems. The group could have learned from questions some participants addressed to me privately. Consulting with me outside the group setting created different knowledge levels because not all participants were exposed to the same information. I tried to confront and minimize this bias by sharing these questions and answers with the group during the workshop sessions.

Recurring Themes in Painting

Impenetrable bubble

Participants drew their students or clients submerged in an impenetrable bubble without the ability to communicate with the person inside. In Figure 3, Claire painted her client submerged in an unpenetrated, see-through womb. She described how she cannot communicate with her client and feels isolated and alone. Michele made a mandala with flowers) Figure 4), and Meggie made two circles (Figure 5). The outer circle was black, representing her struggles to communicate with her client with SM; the inner circle was colorful and joyous, representing the good aspects of her relationship with her client. Madeline expressed difficulties in listening to her client, who whispers very quietly. She explained that the blue circle in the painting symbolizes that her client’s voice is prevented from being heard (Figure 6).

Figure 3 - Claire.

Figure 4 - Michele.

Figure 5 - Meggie.

Figure 6 - Madeline.

Nature imagery

Participants drew nature and flower imagery when asked to portray their clients or students with SM. Nature appeared as the primary component or appeared next to a human figure. Irene made a black flower portraying her client’s portrait (Figure 7). Britt made a predator flower next to her client’s image and explained that she feels terrified of her student’s aggressive behavior (Figure 8). Moly portrayed the first time her student spoke (Figure 9). She said that, for an entire year, she worked with her student with SM, and she felt frustrated not being able to speak with her student and made significant efforts to connect with her student but did not succeed until now. She chose to paint her student wearing her “Purim” (a Jewish holiday) costume rather than her real image.

Figure 7 - Irene.

Figure 8 - Britt.

Figure 9 - Moly.

Omitted body parts

When painting human figures, participants omitted body parts used for communication. Eyes, ears, mouths, and throats were missing. Nina drew only her student’s eyes, saying they were filled with anger (Figure 10). Oliver painted his client’s face, omitting the shape of the head and the entire body (Figure 11). He said he felt he had to be constantly on guard when reaching out to his client. Emily omitted the eyes, ears, and nose, drawing her student’s hair covering her face (Figure 12).

Figure 10 - Nina.

Figure 11 - Oliver.

Figure 12 - Emily.

Summary of Results

In the second research session, participants were asked to paint their client or student diagnosed with SM. Results showed that they tended to depict their student or client in two inner circles they referred to as an impenetrable bubble, paint nature instead of or next to a human figure, and omit body parts, especially those used for communication, when portraying body figures.

Results of Participating in the Research

Some participants said they felt more grounded; most wanted extended support beyond the realms of the research study. Participants in an earlier study expressed feeling more relaxed and focused when they listened to classical music. Thus, based on Hanan’s study (2023), where participants painted self-portraits while listening to Mozart’s Symphony No. 9 in C major, participants in the current study were encouraged to paint with oil pastels and play classical music with their students.

The participants were also trained to work with mandalas. Britt called this learning experience during the research “a magic intervention.” This intervention was introduced because mandalas have been shown to reduce anxiety (Curry & Kasser, 2011), and one goal of working with children with SM is to reduce anxiety levels to promote communication. Thus, mandalas were taught in the professional workshop and based on previous research (Hanan, 2023; Shipon-Blum, 2007).

Participants also commonly expressed feeling more comfortable with their voices through the research process. They learned to embrace positive changes in their self-esteem and gained new perspectives on SM. These findings match Harwood and Bork’s (2011) findings, which specified the importance of professional workshops to increase scholars’ knowledge about SM. Therefore, it is vital to educate and train professionals in the school system and students still in graduate school on how to work with children diagnosed with SM.

In addition, participants in this research study shared that the three workshops were meaningful and significantly affected their confidence when working with SM. They specified that they would have liked more sessions but that these three were impactful because participants learned what is most influential and important when working with SM. Specifically, they learned to work in ways that can reduce anxiety because research has shown that SM is an anxiety-based disorder (APA, 2022; Kaimal & Ray, 2016). Interventions (e.g., mandalas, relaxing music) can lower anxiety levels. It also stressed that participants should focus on building their students’ self-esteem while establishing a social environment that can meet the child’s needs and, most importantly, help the child with SM communicate.

Resources in the Field

This study’s participants shared the need for growing knowledge in the field, especially in educating parents about SM. They wish to continue teaching other professionals and to receive supervision from a professional who knows how to work with children with SM, has a background in expressive arts therapy, and can provide working methods for SM. Teacher participants said that until they participated in this research, they had not known anybody from the expressive arts field who knew how to work with children diagnosed with SM. There is a growing need for supervision for teachers and other professionals to obtain success in working with children diagnosed with SM.

Contribution to the Field of Expressive Arts

When working with children with SM, one often can feel speechless. Art aided me in diving deeper into the participants’ and their students’ and clients’ shared experiences and shed light where there was darkness. Figure 13 shows an art creation I made. It symbolizes the process I went through as a researcher and a leader in my community. Art can help students overcome anxiety related to SM; it is a unique tool for working with SM. Art therapists are thus uniquely capable of facilitating workshops and supporting teachers and parents. It is imperative that art therapists be at the forefront of helping to understand and treat SM.

Figure 13 - Researcher’s response to participants’ artwork.

Limitations

In addition to technical problems with the Zoom software addressed in the Method’s Bias section, which may have affected the overall communication in the research, my enthusiasm for treating SM may have introduced bias in the research study. I can be passionate when discussing the phenomena and perhaps cause the participants to be overly optimistic. This bias might have been better addressed if I had employed a neutral cofacilitator, who might have provided a more objective perspective. This should be considered for future research. Moreover, this research was conducted in Israel. Israel’s culture can be informal in its norms, and communication is often straightforward, open, and direct (Lautmen, 2018). In other cultures where communication norms are more ambiguous and indirect, results of a similar study may differ from these.

Recommendations for Future Research

It is crucial that research in this field continue and explore this phenomenon’s subsets. More research is needed on how art therapy can supply children diagnosed with SM with the ability to increase their self-esteem by exploring nonverbal aspects of their being and finding words to describe how they feel.

Future research is needed to explore the common misconceptions of SM to provide a more guided, precisely developed workshop. It would also be interesting to examine other aspects revealed in this study, such as omitted body parts in drawings by children with SM, professional support systems, and special features seen in the participants’ drawings, such as the flower imagery and the bubble motif. It would also be interesting to explore them to determine whether they are also seen in the art of children diagnosed with SM.

Further research is needed to establish the nature of the relationship between trauma and SM and understand whether traumatic events could cause children diagnosed with SM to show typical SM behaviors. This insight could help professionals understand the body mechanisms involved in trauma that are also connected with SM and provide additional intervention avenues. In addition, more research is needed on the disorder’s etiology, causes, and medical aspects so additional interventions can be developed. Finally, longer workshops that help professionals reconnect with their own emotions, including fears, and implementing art as a way to research their own felt experiences in working with children diagnosed with SM might be useful.