Use of Mandalas in Jungian Play Therapy With Adolescents Diagnosed With ADHD Eric J. Green University of North Texas at Dallas Athena A. Drewes Astor Services for Children & Families, Rhinebeck, New York Janice M. Kominski Johns Hopkins University Adolescent males diagnosed with attention-deficit/hyperactivity disorder (ADHD) typically present with symptoms related to social difficulties, low self-esteem, and externalizing behavior problems. The unique developmental and diagnostic-specific characteristics of adolescent males with ADHD make a verbal approach to abstrac- tions often difficult. Jungian Play Therapy (JPT) provides a creative, potentially beneficial alternative to traditional talk or cognitive therapy to remediate concerns associated with the ADHD diagnosis. The current literature maintains a paucity of creative, developmentally appropriate play (or activity) therapies that mediate typical issues associated with this population. The JPT techniques of drawing and coloring mandalas offer a therapeutic alternative for exploration when counseling adolescents (Baggerly & Green, 2013; Green, 2011). This article features an overview of the current mental health literature of working with adolescents diagnosed with ADHD, as well as illustrates a clinical case study to demonstrate coloring of mandalas may be a beneficial intervention in JPT. Keywords: adolescents, ADHD, Jungian play therapy, mandalas Supplemental materials: http://dx.doi.org/10.1037/a0033719.supp Attention-deficit/hyperactivity disorder (ADHD) is one of the most commonly diagnosed childhood disorders today, with reported rates ranging from 3% to 12% of the total population (Buschgens, van Aken, Swinkels, & Altink, 2008; Froehlich et al., 2007). It is more prevalent in boys than girls, particularly in the diagnosis of the hyperactive/impulsive type (American Psychiatric Association [APA], 2000). Bryan, Burnstein, and Ergul (2004) have explored social and emotional ramifica- Eric J. Green, Department of Counseling, University of North Texas at Dallas; Athena A. Drewes, Astor Services for Children & Families, Rhinebeck, New York; and Janice M. Kominski, Department of Counseling & Human Services, Johns Hopkins University. Special thanks are given to Dawn Romano for her editorial assistance on this article. Correspondence concerning this article should be addressed to Eric J. Green, Counseling Program, University of North Texas at Dallas, 7400 University Hills Boulevard, Dallas, TX 75241. E-mail:
[email protected] T hi s do cu m en t is co py ri gh te d by th e A m er ic an P sy ch ol og ic al A ss oc ia ti on or on e of it s al lie d pu bl is he rs . T hi s ar ti cl e is in te nd ed so le ly fo r th e pe rs on al us e of th e in di vi du al us er an d is no t to be di ss em in at ed br oa dl y. 159 International Journal of Play Therapy © 2013 Association for Play Therapy 2013, Vol. 22, No. 3, 159–172 1555-6824/13/$12.00 DOI: 10.1037/a0033719 http://dx.doi.org/10.1037/a0033719.supp mailto:
[email protected] http://dx.doi.org/10.1037/a0033719 tions associated with special needs students, such as students with ADHD. The deficits that are characteristic of ADHD (i.e., deficits in memory, emotions and behaviors) can cause adolescent males to experience psychosocial as well as edu- cational difficulties in a typical classroom (Graetz, Sawyer, Baghurst, & Hirte, 2006). Specifically, many adolescents with ADHD lack the social networks that their peers and non-ADHD siblings enjoy (Buschgen et al., 2008). Some adolescents who experience social difficulties display internalizing symp- toms, such as anxiety and depressed affect, whereas others externalize their distress through aggressive or violent behaviors (Buschgens et al., 2008; APA, 2000). These minors are at greater risk for multiple psychiatric disorders such as depression, clinically significant anxiety, externalizing behavior disorders, affect dysregulation, illicit substance abuse and dependence, and suicidal ideation (Bryan et al., 2004; Kavale, Holdnack, & Mostert, 2004). TREATMENT APPROACHES Although medical treatment is effective for some children and adolescents diagnosed with ADHD, psychotropic medication can be marginally effective for others (Cortese et al., 2013). Even for those children who show improvement or remediation in psychiatric symptoms with medication, the improvement may be insufficient, or it may be accompanied by adverse side effects (Pelham et al., 2013). In addition, adolescents frequently become resistant and noncompliant with medication management for a variety of reasons (e.g., social stigma, defiance of authority, counterindications with alcohol). Consequently, mental health practitio- ners and researchers have been invested in exploring new ADHD interventions that are nonpharmaceutical and place an emphasis on verbal exchanges to reme- diate symptomologies (Fincher, 2009). The importance of executive functioning and self-regulation in the disorder has led to the successful use of alternative, holistic approaches such as mindfulness meditation training in adults and adoles- cents with ADHD (Zylowska et al., 2008) and the use of art therapy, specifically the mandala, for self-awareness, self-expression, conflict resolution, and healing (Green, Myrick, & Crenshaw, 2013; Slegelis, 1987). The main aspect of a meditative approach and activity, such as the use of the mandala with ADHD clients, is that it is a cognitive and intention-based process characterized by self-regulation and attention to the present moment with an open and accepting orientation toward one’s experiences. This may result in improved attention and concentration as well as possibly offering symptom relief to adolescents coping with negative side effects associated with ADHD (Zylowska et al., 2008). By creating or coloring a mandala, the brain shifts more easily into a meditative state, an alpha wave frequency, which often results in an inner calmness and relaxed state (Beaucaire, 2012). This meditative state occurs as the mandala is being created, colored, or is observed. Consequently, the sense of inner peace, a potential correlation associated with the mandala’s properties, may neutralize causes of stress and might help to reorder one’s thoughts (Green & Drewes, 2013). A mandala is any piece of artwork that is created within a bound shape, customarily a circle (Henderson, Rosen, & Mascaro, 2007). Mandala is a Sanskrit word meaning T hi s do cu m en t is co py ri gh te d by th e A m er ic an P sy ch ol og ic al A ss oc ia ti on or on e of it s al lie d pu bl is he rs . T hi s ar ti cl e is in te nd ed so le ly fo r th e pe rs on al us e of th e in di vi du al us er an d is no t to be di ss em in at ed br oa dl y. 160 Green, Drewes, and Kominski “sacred circle” (Fincher, 2000). The circular shape of a mandala connotes whole- ness and integration. Mandalas can be found in the sacred artwork of cultures throughout time, from cave drawings and rock carvings to sand paintings and stained glass windows. A mandala, or magic circle, is used as a meditative tool in various religions, but most famously in Tibetan Buddhism. The mandala circle (with inner symbolic patterns) may promote psychological healing through the calmness created from a peaceful state of mind when created by an individual (Mahar, Iwasiw, & Evans, 2012). Jungian Play Therapy Jungian play therapy (JPT) offers an alternative to traditional talk therapy. JPT is a particular form of play therapy that facilitates healing through the expression of one’s subconscious images, metaphors, and symbols based on analytical psychol- ogy (Green, 2009). The language of JPT is visual rather than verbal; Jungian therapists encourage clients to produce and recall symbols in sandplay®, journals, dream work, and artwork (Allan & Bertoia, 1992; Green, 2008, 2010b). The goal of JPT is to help children grow toward wholeness (individuation) and thereby achieve their unique potential. The process also involves a clinician modeling and helping the child by developing a symbolic attitude, which means forming a meaningful connection between inner and outer realities by paying attention to symbols produced by the psyche in dreams, fantasies, sandplay®, and artwork. Children and adolescents often do not have the developmental capacity to reveal and resolve difficult or complex feelings, thoughts, and needs verbally. Play therapy provides a developmentally appropriate mode of expression for children, adolescents, and any other client who may not be ready to verbally process experiences, thoughts, and emotions (Allan, 1988; Green, 2008; Landreth, 2012). In order to heal, individuals must reconcile the disparate aspects of their personality. Children and adolescents learn to integrate and honor those parts of themselves that they believe society or influential others find unacceptable. These parts are integrated so that they do not remain banished to the shadow. The shadow is all of those traits an individual might not be consciously aware of and may find repre- hensible or too aberrant to contain in conscious ego awareness. Drawing and coloring mandalas are JPT techniques that creatively facilitate therapeutic exploration in children and adolescents, especially those with ADHD. The use of JPT techniques such as analysis and interpretation allow symbols to surface within the temenos (i.e., emotionally safe and protected space) of the therapeutic alliance (Green, 2012a). The patient may then gain awareness of these shadow aspects and seek to integrate these disowned parts (or figures) to become a psychologically whole individual. In JPT, the healing is not accomplished from therapeutic techniques; rather, it is derived through the personal self-healing ar- chetype that emerges within the safety of the therapeutic relationship (Green, 2009). The self-healing archetype is an innate symbol that promotes psychic healing by recognizing and achieving a balanced communication between the ego and the Self (between the individual’s inscape and external reality). An adolescent’s un- derstanding of the self-healing archetype is not required for the psyche to undergo T hi s do cu m en t is co py ri gh te d by th e A m er ic an P sy ch ol og ic al A ss oc ia ti on or on e of it s al lie d pu bl is he rs . T hi s ar ti cl e is in te nd ed so le ly fo r th e pe rs on al us e of th e in di vi du al us er an d is no t to be di ss em in at ed br oa dl y. 161Use of Mandalas healing. Bedford Ulanov (2007) explains, “It is the experience of the numinous that heals, not our understanding of it . . .” (p. 237). Role of the Jungian Therapist Jungian play therapists do not analyze their clients’ work for them; rather, they assist the client to interpret and find meaning from their own phenomenological perspective (Allan & Brown, 1993; Castellana & Donfancesco, 2005; Green & Hebert, 2006; Green, 2011). Therefore, the Jungian-oriented play therapist does not assume an expert role in the context of counseling; JPT is an intersubjective experience between therapist and client or a dialectic built on transference projec- tions that occur to promote healing. Play therapists believe in the power of the self-healing archetype of the client (believes in the child’s psyche to produce the symbols that will lead toward self-healing) and serves as a facilitator to introduce creative activities to activate that self-healing archetype within the child. While working with a child (or adolescent), the Jungian play therapist may comment on the child’s work and allude to the psychosocial issues the child is currently expe- riencing if the child’s ego is ready to integrate this material. By verbally linking the child’s concrete drawings with real-life abstractions (otherwise known as interpre- tations), the therapist helps to bring into awareness the unconscious symbols that the child has produced to further pave the way to intrapsychic self-healing. Applicability of JPT With ADHD Adolescent Males Adolescence often comprises crises of identity with opportunities to expe- rience growth toward individuation or “psychological wholeness” (Green, 2011; Patton, 2006). JPT is a modality that presents adolescents with a symbolic, emotionally safe outlet to recover disowned or disconnected cognitions and emotions in less-threatening ways (Allan & Brown, 1993). This is particularly beneficial if the adolescent is unable to cognitively, verbally, or emotionally address difficult analytical material and would otherwise be overwhelmed by the associated emerging affect. The use of the mandala, specifically, allows the adolescent with ADHD a nonverbal or less verbal approach that engenders a potentially healing medita- tive effect. Individuals can experience relaxation and psychological healing leading to a discovery of personal meaning through meditating and/or creating mandalas (Henderson et al., 2007). In analytical terms, mandalas promote healing by facilitating intrapsychic communication between the Self and the ego through archetypal symbols and their associated or collective affective under- tones. That which is unconscious is brought to consciousness through the creation of the mandala. Although there is little empirical research focusing on the use of mandalas as an effective mental health intervention specifically with ADHD adolescents, Hen- derson et al.’s (2007) results provided initial empirical support that warrants further study. They found that a sample of individuals suffering from posttraumatic stress T hi s do cu m en t is co py ri gh te d by th e A m er ic an P sy ch ol og ic al A ss oc ia ti on or on e of it s al lie d pu bl is he rs . T hi s ar ti cl e is in te nd ed so le ly fo r th e pe rs on al us e of th e in di vi du al us er an d is no t to be di ss em in at ed br oa dl y. 162 Green, Drewes, and Kominski disorder experienced a reduction in trauma symptoms after they drew symbols and representations of their trauma and emotional response within mandalas. Hender- son et al. note that case studies and clinical observations consistently support the efficacy of mandalas as a medium of healing, particularly in cases where the clients or patients are unable to express themselves verbally due to trauma, shame, or cognitive deficit. Use of Mandalas in Jungian Play Psychotherapy Mandalas may be a beneficial tool for ADHD adolescents as they begin thinking about and expressing their thoughts and feelings in a safe and con- tained space. Mandalas were chosen by the therapist in the case study later in this article to use with the adolescent, over other types of expressive art therapy interventions, because the adolescent expressed an interest in the activity. The mandala sometimes helps the client to focus, center himself emotionally and cognitively into the task at hand, while allowing the therapeutic components of the experience to aid in emotional healing and integration (Fincher, 2009). The process of creating a mandala, as seen in this article’s case example, helped the client to become more conscious of his inner thoughts and facilitated reflection and relaxation. Coloring and/or creating mandalas has been used in mental health contexts with numerous populations and settings, including posttraumatic stress disorder and dissociative disorders (Cox & Cohen, 2000), traumatic grief (Pizarro, 2004; Henderson et al., 2007) and ADHD (Smitherman-Brown & Church, 1996). As mentioned previously, pure empirical research on the use of mandalas as a thera- peutic tool is sparse. Most research into the healing aspects of mandala drawing has been limited to case studies and clinical observations (Couch, 1997; Henderson, 2007; Kellogg, Mac Rae, Bonny, & di Leo, 1977; Smitherman-Brown & Church, 1996), although they do provide promising results. Slegelis (1987) sought to exam- ine Jung’s tenet that drawing within the circular form of the mandala promotes psychological healing. More specifically, the nonverbal task of drawing mandalas would be expected to have a calming effect on their creators. Although the results of this study lends support to the argument that mandalas have calming and healing properties, the design and analyses are relatively weak and thus limit the inferences that can be drawn from the results. Curry and Kasser (2005) examined the useful- ness of coloring mandalas to reduce anxiety. They assessed levels of anxiety before and after coloring of a mandala. They found that of the three conditions (free-form, plaid-form, and mandala drawing) individuals showed a decrease in anxiety in the mandala drawing as well as the plaid-form condition. The control group showed no decrease in anxiety. The results demonstrated that coloring mandalas did reduce levels of clinically significant anxiety. van der Vennet and Serice (2012) conducted an experimental-design replication study of Curry and Kasser’s (2005) research that tested whether coloring a mandala would reduce anxiety. Anxiety levels were measured by participants with the State Anxiety Inventory at the onset, after a writing exercise, and after coloring a mandala (American Psychological Associa- tion, 2013). Empirical results supported the notion that coloring a mandala reduces T hi s do cu m en t is co py ri gh te d by th e A m er ic an P sy ch ol og ic al A ss oc ia ti on or on e of it s al lie d pu bl is he rs . T hi s ar ti cl e is in te nd ed so le ly fo r th e pe rs on al us e of th e in di vi du al us er an d is no t to be di ss em in at ed br oa dl y. 163Use of Mandalas anxiety to a clinically significant degree than merely coloring on a blank piece of paper. The use of the mandala as a therapeutic tool was first introduced by Giordono Bruno in the 16h century and later by Carl Jung (1973), who suggested that the act of drawing mandalas had a calming and healing effect on its creator while at the same time facilitating psychic integration and personal meaning in life. Jung ex- plored the psychological meaning of mandalas, viewing them as symbolic of the inner process from which individuals grow toward fulfilling their potential for wholeness. He surmised that the mandala was a manifestation of the individual psyche’s self-regulating system, which helps to maintain our orderly functioning and can, when needed, restore stability (Fincher, 2009). Jung saw in the nonverbal creation of mandalas of his clients, a natural process of generating and resolving inner conflicts that would bring about greater complexity, harmony, and stability in the personality. The mandala functions as a symbolic representation of affective material constel- lated in the psyche yet unknown or unconscious to the individual, yet at the same time provides a sense of order through concentration and integration to this material (Henderson, 2007). The power of such imaginative psychic concentration is used in modern psychotherapy, and its positive content is a therapeutic tool used in cognitive and behavioristic forms of psychotherapy as part of the relaxation principle. In situa- tions of stress and fear the concentrated visualization of a personal healing mandala can have protective effects on the individual, even helping to generate new patterns of protective processes and coping mechanisms (Bonny & Kellogg, 1977). Meditative Qualities and Benefits of Mandalas Meditation causes the brain to operate on an alpha wavelength, which are slow- frequency waves with a high rate of electricity that appears on an EEG when the body is in a state of relaxation. The frequency begins at 8–13 Hz and gradually decreases to a frequency of 8–10 Hz as the body begins to enter into a state of deeper sleep, resulting in a drop in the heartbeat along with muscular relaxation (Beaucaire, 2012). The goal of meditation is to raise the brain to an alpha wave frequency while in a wakeful state. Physiologically, by drawing a mandala the brain’s right hemisphere (responsible for emotions, feelings, imagination, and associations) makes it possible for the left hemisphere (which rules linear reasoning and problem solving) to rest and be suppressed. Combining mandala drawing and coloring with guided imagery may result in a meditative state that helps the individual feel calm but also facilitates inner reflection and visualization (Buchalter, 2013). Coloring mandalas results in a reduction in anxiety as it allows the mind to escape from thoughts and teaches an individual patience (Polt, 2005). Polt exam- ined levels of depression, anxiety, and energy and concentration before and after mandala coloring. The results demonstrated that coloring mandalas did reduce levels of depression and anxiety, as well as led to an increase in energy and concentration. Mandalas are often used by play therapists working from a JPT orientation, as well as by art and expressive arts therapists (Green, 2009). T hi s do cu m en t is co py ri gh te d by th e A m er ic an P sy ch ol og ic al A ss oc ia ti on or on e of it s al lie d pu bl is he rs . T hi s ar ti cl e is in te nd ed so le ly fo r th e pe rs on al us e of th e in di vi du al us er an d is no t to be di ss em in at ed br oa dl y. 164 Green, Drewes, and Kominski CLINICAL VIGNETTE The following sections focus on the explication of the analytical play frame- work of incorporating mandalas with adolescents. Next, therapeutic benefits of using mandalas with an adolescent boy with ADHD, through a case study, are highlighted as an alternative treatment approach. The following case study was conducted to help facilitate treatment by offering a nonverbal, meditative, expres- sive art therapy approach on a short-term basis. Both therapist and client were willing to try the use of the mandala. The therapist counseled the adolescent twice per week over a 3-month period, which included a parent interview and subsequent family therapy sessions with the adolescent involved. The therapist has advanced play therapy experience and educational training in analytical approaches to play psychotherapy and Jungian sandplay® therapy and works part-time in a indepen- dent practice setting seeing mainly children and adolescents using play therapy and sandplay®. The predrawn mandalas were from a workbook containing 30 designs (Green, 2013). Predrawn mandalas were used for coloring purposes. During the mandala drawing session, the therapist read a guided imagery script to help the adolescents relax, awaken the Self, and generate ideas for drawing his own mandala. The script was a simplified version of one written by Green (2010a). It was adapted to include vocabulary appropriate for early adolescents and abridged slightly to be brief in time duration as to accommodate the short attention span of a typical adolescent boy diagnosed with ADHD (Raffaelli, Crockett, & Shen, 2005). The script guides the listener on a metaphorical journey to the unconscious and then presents a series of central archetypes to imagine such as the Wise Old King, the Holy Child, and Mother Earth. It concludes with instructions for creating one’s own mandala including two or three symbols. During each session the therapist prefaced the reading of the script with a brief explanation and discussion of the term archetype. Identifying information in the following clinical vignette has been changed to protect the confidentiality of the adolescent’s information. Psychosocial and Psychopharmacological Data Jeremy is a 13-year old, seventh-grade student who was diagnosed with ADHD, dysgraphia, and sequencing difficulties in first grade. Jeremy takes 72 mg per day of Concerta medication for ADHD, has been receiving individual counseling, and currently participates in weekly social skills groups at his middle school. Concerta is a central nervous system stimulant prescribed to treat hyperactivity and impulse control. It has common side effects such as insomnia, aggression, and a loss of appetite. Jeremy has excellent verbal abilities and excels academically in math and science. He has difficulty with writing as he reports feeling overwhelmed when reading assignments, and he experiences cognitive difficulty reducing larger assignments into smaller tasks. When pre- sented with a multistep school project, Jeremy display disproportionate anxiety because he remains cognitively preoccupied about the size and scope of the project. He articulates that his apprehensions center around his thinking process T hi s do cu m en t is co py ri gh te d by th e A m er ic an P sy ch ol og ic al A ss oc ia ti on or on e of it s al lie d pu bl is he rs . T hi s ar ti cl e is in te nd ed so le ly fo r th e pe rs on al us e of th e in di vi du al us er an d is no t to be di ss em in at ed br oa dl y. 165Use of Mandalas of being unable to complete it. Jeremy has difficulty organizing his schoolwork and misplaces assignments between home and school. Despite these challenges, Jeremy maintains a “B” average in school. At times, Jeremy presents with hypersensitivity, both emotionally and physi- cally. He has a history of being bullied and responds by participating in self- defeating beliefs and feeling hopelessness. Jeremy internalizes the unfair treatment by his peers. Specifically, he asks the play therapist what is wrong with him and assumes that he is at fault for his peers’ mistreatment. He easily becomes frustrated and upset; he cries and questions his parents, “Why did God make me this way?” A personal strength has emerged from Jeremy’s social trials: he is acutely aware of others’ pain and reaches out to others who are bullied, teased, or whom he perceives to be hurting. Analytical Process of Incorporating Mandalas in Clinical Work Throughout therapy, Jeremy typically chose to verbally discuss issues with his therapist. However, the therapist did provide him with options to consider such as sandplay®, artwork, dream work, and coloring mandalas. The client was in the position to choose when he wanted to incorporate mandalas and at what stages. The first time he elected to color a mandala started with a relaxation technique. With Jeremy’s eyes closed in a comfortable seated position, the therapist led the ado- lescent through a guided imagery technique for several minutes. Jeremy then selected a preconfigured mandala from several choices contained within a work- book and created some of his own original ones in a blank circular shape (Green, 2013). The therapist instructed Jeremy to color the mandala. While the mandala was being colored, the therapist played nature-sounding relaxation music to inten- sify the relaxation response (Saarikallio & Erkkilä, 2007). Once the client finished coloring, the image was briefly contained (the patient contemplates the mandala in silence for 15–30 s). According to Allan (1988), children can benefit from art therapy if the interventions provided help with individual expression and commu- nication of the artistic creation from a phenomenological perspective. The client was then instructed to create a color key (similar to a map key) to represent what each color represents on the mandala to him. The client was then encouraged to “write the story of the mandala” on the back of the coloring page. Afterward, the therapist simply said, “Is there anything you’d like to share with me about your mandala?” If not, just as in sandplay®, there is no mandatory or expected therapist- led verbal processing after. However, some children and adolescents are verbose when it comes to explaining their unique creative activities. In that case, a therapist may choose to ask one or two of the following questions after the mandala is colored: (1) What’s the story of your mandala? (2) If you were inside this mandala, what might you be feeling like? (3) What were you thinking/feeling as you were coloring this part of the mandala? and (4) How could this image relate or remind you of a part of yourself? Jeremy was interested in drawing his own mandala and quickly grasped the concept after being provided a simple overview by the therapist. He felt comfortable enough to close his eyes during the reading of the script and was able to focus through T hi s do cu m en t is co py ri gh te d by th e A m er ic an P sy ch ol og ic al A ss oc ia ti on or on e of it s al lie d pu bl is he rs . T hi s ar ti cl e is in te nd ed so le ly fo r th e pe rs on al us e of th e in di vi du al us er an d is no t to be di ss em in at ed br oa dl y. 166 Green, Drewes, and Kominski the entire script by dispelling some of his energy through moving his hands and feet while listening. At the conclusion of the reading of the script he knew exactly what he wanted to draw. He had recently studied mythology in school and therefore was familiar with the Greek and Roman names for some of the archetypes. He drew three symbols in this order: the winged foot of Hermes, the sword and scroll of Athena, and a cross with a halo which he labeled as the Holy Child (see Figure 1). Jeremy explained that he thought of speed and gracefulness when he thought of Hermes, and, as a runner, he identified those qualities within himself. He recognized Athena as a great scholar of wisdom and knowledge and a defender of liberty. Jeremy indicated his belief of possessing the qualities of wisdom and particularly knowledge. He explained that he felt strongly about standing up for his peers’ right to speak their mind in the classroom, provided they were discussing things pertinent to the lesson at the time. He expressed that it was most important for him to stand up for those students who were not “popular, rich or had famous relatives.” Jeremy labeled the cross and halo as the Holy Child but discussed it as “a Redeemer, Forgiver, and the Savior.” He explained that he felt that he was good at forgiving people and that when faced with peers saying or doing unkind things to him he chose to “. . . try to let it go and say to [himself], ‘they don’t know what they’re doing’ and to forgive them, too.” He lamented, “It is very rare that I meet people who actually care about who I am instead of caring if I’m popular, or rich or have famous relatives.” He then went on to share how his own experiences have helped him to develop empathy and awareness of instances when other people are hurting but try to conceal the hurt with false displays of happiness. Jeremy re- counted a particular incident with a fellow student who had said someone he “really loved” had died. Jeremy became teary as he explained, “I felt sad for [him] and actually almost started to cry.” He briefly discussed how he had tried to comfort the Figure 1. Jeremy’s drawn mandala. For a color version of this figure, please see the supplemental materials link on the first page of this article. T hi s do cu m en t is co py ri gh te d by th e A m er ic an P sy ch ol og ic al A ss oc ia ti on or on e of it s al lie d pu bl is he rs . T hi s ar ti cl e is in te nd ed so le ly fo r th e pe rs on al us e of th e in di vi du al us er an d is no t to be di ss em in at ed br oa dl y. 167Use of Mandalas classmate. The play therapist used amplification, a Jungian intervention that entails helping a client carry forward images and symbols to further delve into their meaning through artistic means (Green, 2012b). The therapist suggested that he draw a symbol for this, and Jeremy drew a series of interconnected hearts to symbolize the “love that kept growing and growing” in the family. Jeremy appeared to feel soothed by creating and coloring the symbol as evidenced by his relaxed shoulder stance and facial muscles. During the second session of coloring mandalas, Jeremy selected a design of a series of overlapping circles that created seven overlapping flower-type designs with six petals each. Fincher (2000) identifies this as a Hindu design representing Creation from the Great Round stage of Crystallization, “a time of fulfillment, satisfaction, and completion” (p. 14). Jeremy did not see this caption. Initially, Jeremy talked profusely and although he continued coloring, he was frequently distracted by various stimuli including the names of the colors and Spanish translations of words printed on the crayons. After a few minutes of quiet coloring he began to talk about something in his life that was causing him anxiety: the change in the family’s usual summer vacation to attend a family wedding. He began to color inward within his boundaries of the inner mandala he had created. He shifted topic conversation back to the crayon colors as he switched to color between the inner and outer mandalas. He worked in circular motions throughout the course of the task, turning the paper in circles as he worked and became quiet. He remained quiet until he became anxious after accidentally coloring a small portion of the drawing a color he hadn’t intended; at that time he tensed his shoulders and spoke to express his frustration and disappointment. The therapist acknowledged his intent and reflected his feelings. He relaxed his shoulders, switched to another dialogue about the crayon colors before trailing off and returning to work silently for several moments. He made conventional color choices for the sun, sky, clouds and grass; yet, unconventional choices for the gold stem, silver buds, and brown petals (see Figure 2). Jeremy described the title of the mandala as “the flower of life.” In describing the story of the mandala he told a creation story, starting with “let there be light” from a divine figure that he also described as “the hope that keeps you going.” He went on to describe (a) the grass as a “lifebearer” for the flower of life (i.e., a Mother Earth reference), (b) the sky as a space where birds could fly freely or the sea floating on itself (i.e., possibly a reference to the dividing of the waters into sky and sea in the Judeo-Christian Creation story), (c) the stem of the flower akin to the golden horn of a newborn unicorn to him signifying birth (i.e., the Divine Child), (d) the silver bud of the flower like the silver horn of a mature unicorn (i.e., the Animus or masculine archetype), and (e) the brown of the flower he dubbed “the soul, the part of you that even when you die it won’t” (i.e., this may represent the Self archetype). Jeremy colored his soul brown. Allan (1988) suggests that the use of brown in children’s drawings often signifies “inhibitions, repression, and depression” (p. 148). Yet, when the therapist asked how he would feel if he were in this picture, Jeremy said he would feel “pretty happy” and even indicated where he would lie on the grass in the picture. At the end of the session Jeremy spoke about the brown petals again and said they were brown like the dirt that “has the nutrients for you to keep you going” and said cheerfully that brown was a beautiful color for a flower. T hi s do cu m en t is co py ri gh te d by th e A m er ic an P sy ch ol og ic al A ss oc ia ti on or on e of it s al lie d pu bl is he rs . T hi s ar ti cl e is in te nd ed so le ly fo r th e pe rs on al us e of th e in di vi du al us er an d is no t to be di ss em in at ed br oa dl y. 168 Green, Drewes, and Kominski Analysis As a survivor of bullying and a student with special needs, Jeremy often dwelled on his social challenges to connect with other peers and his minor academic shortcomings. Creating his own mandala encouraged intrapsychic healing, promoted development of the Self, and provided Jeremy with an opportunity to recognize and appreciate his positive qualities such as speed, grace, wisdom, mercy, and righteousness. Jeremy’s colored “Creation” mandala was replete with representations and references to archetypes from the collec- tive unconscious; it is unlikely that strict talk therapy would have brought forth this wealth of healing symbols for Jeremy. Both drawing and coloring mandalas allowed Jeremy to externalize personal images in a visual medium. This visual representation created a bridge that allowed him to become aware of his internal strengths and verbally process abstractions with the therapist. Imme- diate benefit was seen in the case study, whereby the client was able to relax during the mandala coloring and with the aide of a guided imagery meditation could elicit personal symbols and metaphors regarding his life. The process of creating the mandalas and the personal interpretation of them helped him to gain access to and underscore personal strengths. The therapeutic outcome at the termination of psychotherapy was positive, as the adolescent self-reported feeling less stress and more emotionally available to communicate with those around him, especially his peers. The therapist also advocated for this child at his school for a safer emotional and physical environment from the bullying that was occurring. Figure 2. Jeremy’s colored mandala. For a color version of this figure, please see the supplemental materials link on the first page of this article. T hi s do cu m en t is co py ri gh te d by th e A m er ic an P sy ch ol og ic al A ss oc ia ti on or on e of it s al lie d pu bl is he rs . T hi s ar ti cl e is in te nd ed so le ly fo r th e pe rs on al us e of th e in di vi du al us er an d is no t to be di ss em in at ed br oa dl y. 169Use of Mandalas CLINICAL IMPLICATIONS FOR PLAY THERAPISTS Using mandalas with adolescent males with ADHD may provide access to self-healing material through its meditative process. Play therapists planning to incorporate mandalas into individual therapy should consider several factors in order to provide the greatest benefit to clients. To familiarize the client with the concept of mandalas, it is generally considered more facilitative to ask clients to color predrawn mandalas before creating their own so that they have a tangible contextualization from which to build on (Cox & Cohen, 2000). Second, play therapists may want to provide a brief overview of archetypes as the authors did at the beginning of this article. Adolescents understand what symbols are, but may not be familiar with the term archetypes. However, this is not cogent as the term archetype can be removed from the guided imagery exercise and replaced with the word “symbol.” Third, play therapists need to engage in continuous psychodiag- nostic assessment to evaluate their client’s abilities. Clients do not need to be able to consciously interpret their mandalas to benefit from coloring them; the emer- gence of the self-healing archetype is what heals (Baggerly & Green, 2013; Green, 2009). However, drawing mandalas does require some abstracting ability; therefore, therapists should consider their client’s abstract reasoning abilities in order to avoid or limit psychological frustration. The play therapist should acquire training in basic art therapy principles to understand the expressive art therapy intervention’s rationale, utility, and healing potential within the psychotherapeutic context. Also, play therapists should seek professional development and training in guided imagery before using it as a conduit to expressive art therapy interventions. Therapists must ethically practice only within their scope of supervised training and education, especially play ther- apist seeking to incorporate tenets from the expressive art therapy modalities (Green & Drewes, 2013). Moreover, play therapists must receive specialized train- ing in JPT and interpreting mandalas before attempting to integrate these types of specialized treatment approaches. 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Journal of Attention Disorders, 11, 737–746. doi:10.1177/1087054707308502 Received November 5, 2009 Revision received May 20, 2013 Accepted May 21, 2013 � T hi s do cu m en t is co py ri gh te d by th e A m er ic an P sy ch ol og ic al A ss oc ia ti on or on e of it s al lie d pu bl is he rs . T hi s ar ti cl e is in te nd ed so le ly fo r th e pe rs on al us e of th e in di vi du al us er an d is no t to be di ss em in at ed br oa dl y. 172 Green, Drewes, and Kominski http://dx.doi.org/10.1037/a0032323 repository.tamu.edu/bitstream/handle/1969.1/ETD-TAMU-1604/HENDERSON-THESIS.pdf repository.tamu.edu/bitstream/handle/1969.1/ETD-TAMU-1604/HENDERSON-THESIS.pdf http://dx.doi.org/10.1037/1931-3896.1.3.148 http://dx.doi.org/10.2307/1593630 http://dx.doi.org/10.1515/1548-923X.2313 http://dx.doi.org/10.1177/1049909106289087 http://dx.doi.org/10.1080/07421656.2004.10129327 http://dx.doi.org/10.1080/07421656.2004.10129327 http://dx.doi.org/10.3200/GNTP.166.1.54-76 http://dx.doi.org/10.3200/GNTP.166.1.54-76 http://dx.doi.org/10.1177/0305735607068889 http://dx.doi.org/10.1016/0197-4556%2887%2990018-9 http://dx.doi.org/10.1177/1087054707308502 Use of Mandalas in Jungian Play Therapy With Adolescents Diagnosed With ADHD Treatment Approaches Jungian Play Therapy Role of the Jungian Therapist Applicability of JPT With ADHD Adolescent Males Use of Mandalas in Jungian Play Psychotherapy Meditative Qualities and Benefits of Mandalas Clinical Vignette Psychosocial and Psychopharmacological Data Analytical Process of Incorporating Mandalas in Clinical Work Analysis Clinical Implications for Play Therapists References