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Art work: Another dimension in the treatment of psychiatric patients
Art
Psychotherapy,
Vol. 5 pp. 71-79.
Pergamon Press, 1978.
Printed
in
the U.S.A.
ART WORK: ANOTHER DIMENSION IN THE TREATMENT OF PSYCHIATRIC PATIENTS* PAULINE S. POWERS, M.D. University of South Florida College of Medicine JOY LANGWORTHY, O.T.R. Veterans Administration Hospital Tampa, Florida Art work, as an integral part of a holistic treatment program, reflects the changes a person makes in therapy, and is also a medium which promotes the individual’s awareness of his own feelings and interactions with others so that he may choose whether or not to change. Art work can also facilitate change in therapy. Four major principles of Social Psychiatry are mherent in the interpretations of the art work to be described. These principles include the following: (1) Every person should be the subject and not the object of an interaction. (2) What one person does affects those around him. (3) No problem can be solved without the involvement and contribution of all fields, including medicine, social work, architecture, education, and research. (4) Isolated information about any person becomes meaningful only when incorporated into the total fabric of that person’s life (Carleton). Two group projects to which ail members contributed wiIl be shown and discussed in terms of the group process which culminated in each project. Each individual’s unique contribution to the group project and the relevance this contribution has .in terms of his personality structure, role in the group, and current psychotherapeutic changes, will be discussed. The group projects also reflect attitudes and events in the larger therapeutic community or in other areas of the social network impinging on the art group and its members. Also a detailed description of the course of treatment for one patient will
be presented, utilizing photographs of her art work to hi~i~t the discussion. GROUP PROJECT: “THE CIRCUS” The Circus (Fig. 1) was a project done by a group of adolescents in short-term therapy (3-6 months). All were hospitalized at the time of this project. Two therapists and one medical student also contributed to the project. The hospital setting is a therapeutic comm~i~ designed to encompass the principles of sociJ psychiatry. At the time of this work most of the patients had been hospitaiized at least a month. The major intrapsychic problems of each patient had been identified. Only one patient was near discharge and there was a sense of cohesiveness on the ward. Just prior to the therapy session there had been a community meeting during which several members (patients and staff) complained of being overweight. One of the staff members suggested forming a weight reduction group and the patients enthusiastically elaborated on the idea with the resultant plan that several patients and staff would meet each other for lunch in the communal dining room, encourage one another not to eat, and they agreed that one of the patients (not in the art grtiup) would chart daily weights. The community meeting ended in a spirit of cooperativeness and several people including patients, two janitors, and members of the clinical staff began weight charts. Shortly thereafter the art group began. Ini-
*Requests for reprints should be sent to Pauline S. Powers, M.D., Assistant Professor of Psychiatry, University of South Florida College of Medicine, 12901 North 30th Street, Tampa, Florida 33612. 0090-9092178/0407-007SO2.00/0
Copyright 0 1978Pergamon Press, Inc.
POWERS AND LANGWORTHY
72
Fig. 1 tially there was much talking and laughing about the weight plan and wondering what to do in the art group. One of the therapists suggested a group project and another member suggested a circus. The group was cohesive, and the mood of cooperation doubtless reflected the general mood of the larger therapeutic community. Throughout the art group there was warm lighthearted interaction among the members. Production of the project also helped improve cohesiveness in the group and underscored the feeling of warmth and intimacy prevailing in the larger social network. The follo~ng is a description of each indi~du~‘s contribution to the art group and the relevance it has to each person’s personality characteristics and group role. The cage for the animals in the Circus, the ramp and some of the wheels were constructed by one of the co-therapists, who was also Director of the Adolescent Unit which forms the larger therapeutic community. She initiated the project and felt responsible for providing the support system. It was originally meant to be a wagon but turned out to be a cage and she suspects it reflects her ambivalence toward the involuntary hospitalization of most of these adolescents (many are hospitalized by their parents or the court for treatment) and the difficulty in providing adequate protection for the
adolescent without “caging him in” and permitting the youngster sufficient autonomy to develop a sense of identity. This therapist probably also unrealistically saw herself as the major support system for the therapeutic community, the art group, and her family and responsible “for getting the show on the road” in all these areas. Sybil formed a large, slightly distorted rabbit with whiskers and put the rabbit in the cage. Sybil is a IS-year-old adolescent with a three-year history of drug abuse, frequent runaways, shoplifting and forgery. When Sybil was a toddler she did not know her father, and her mother was often emotionally unavailable, usually drinking or moving the family from place to place. When Sybil was about 4, her mother formed a lasting attachment with a boyfriend who spent much time with the family. The boyfriend died when Sybil was 10 and she and her mother stopped communicating. Sybil began a series of acting-out behaviors which probably reflected an unresolved grief reaction. The diagnostic impression was that she had a borderiine person~ity with insufficient individuation and separation from her mother, and that the loss of the boyfriend who served as a pseudo-stepfather triggered the dramatic acting-out behavior. The treatment plan (Masterson, 1972) was to (1) initially prevent acting-out be-
ART WORK:
ANOTHER
DIMENSION IN THE TREATMENT
OF PSYCHIATRIC
PATIENTS
73
Fig. 2 havior in a structured environment, (2) then to help her connect her behavior and subjective feeling state, (3) then traditional insight psychotherapy focusing on her rage and depression about her mother’s emotional distance, rekindled with the loss of her pseudo-stepfather. The art group was but one aspect of a holistic treatment program designed with this psychodynamic formulation in mind. Initially, in treatment, her work was two-dimensional including a human figure (Fig. 2) and a flat elephant which she described as herself. Early in the second phase of treatment, she formed a distorted human figure in a coffin and soon after formed the rabbit which was part of the circus. She asked th.e therapist what the rabbit meant and the therapist responded that “rabbits run”; she then said that she wanted the staff to put her on escape precautions
and talked about her anger about the possibility of a foster home (which would have represented another loss). Probably the rabbit symbolized her desire to run from her feelings. Sybil also formed a large frog’s head for the circus which she perched on the edge of the cage and she also formed a snake which she put on the ramp. She talked little about these animals but the frog is watchful and may represent a critical superego and the snake may represent the covert, sneaky, unacceptable part of herself. Ron contributed two wheels, copied Sybil’s snake and made a sign for the circus saying “fat asses”. He is a 13-year-old adolescent with a number of difficulties with the police, including running away, breaking and entering, and destroying property in his father’s home. His course on the ward
74
POWERSANDLANGWORTHY
was stormy with many violent agitated episodes occurring consistently after his father’s lack of participation in family therapy. He was also very susceptible to peer pressure and agreed to almost anything the other youngsters planned. His work throughout the art group was often imitative. He was thought to have very fluid ego boundaries and this was reflected in his art work. Despite his angry flare-ups, he was an affectionate youngster, wellliked by staff and patients but unable to express his affection openly. His sign “fat asses” was formed in a good-natured mood and probably reflects his difficulty in admitting any warm feelings. Kevin, a 14-year-old boy, contributed a small bird sitting on the edge of the cage. Kevin was a shy, withdrawn youngster with the diagnosis of schizoid personality. At the time of this project, Kevin was often on the edge of the art group, both emotionally and physically, sometimes moving his chair slightly away from the group, talking little to other group members. Louis was 17 at the time he contributed a small smirking head to the circus. He was admitted to the hospital in an acute psychotic episode with staring, posturing and paranoid ideation. He began art therapy a month after he was admitted and initially made several unusual flowing forms which he said “were neither one thing nor the other” and which we thought were very representative of his weak ego boundaries and vague, ill-defined sense of self. In one session he made a very realistic skull, remarking that he would like to tear the skin off the face of one therapist, because she had not agreed to a pass for the weekend during an earlier community meeting. Later he couldn’t remember he had ever been angry. In this session he spontaneously contributed the small head. The rest of the work he did in clay was flowing, abstract, and non-structured, some of which looked vaguely like human figures and one in particular looked like a monk (Fig. 3). The therapists’ reactions to this youngster were interesting. Neither of us could remember his name after he was discharged even though he had been hospitalized several months; we didn’t take pictures of all his work separately. When we were preparing an exhibit of several of the adolescents’ work, we initially forgot he had contributed anything to the circus. The other therapist contributed the elephant and said elephants were always associated with happiness in childhood. She is, however, quite thin and has difficulty gaining weight and thought her contribu-
tion represented her desire to belong to the group. even though she was very aware of her thinness. Traci is a 13-year-old black female with Anorexia Nervosa, whose work is described in the subsequent case report. By the time of this project she had gained 15 pounds but was still markedly underweight and was very angry; she expressed her anger on the ward by passive-aggressive .means (for example, by vomiting into the pillows in the day room). Her contribution to the project was made only after prompting by several members of the group who suggested a plaque entitled “Slim Gyms”. She made a plaque entitled “Slim Jills” and this was thought to be another angry response to being told what to do and probably also reflected her anger at not being part of the weight-reduction group that had formed on the ward. Brian, a 22-year-old medical student taking part of his training with the adolescent unit, made several animals for the project, including a group of three animals and the hippopotamus. His first work in the art group in an earlier session was of an arm protectively extended. Most of his other contributions were warm, comforting figures. He was very comfortable in this cohesive group session, but in other sessions made figures or projects to produce cohesion or eliminate conflict. This was his pattern in ward interactions as well, where he often assumed the role of a peacemaker or mediator and was very uncomfortable with angry feelings and did not reveal his own anger. Sarah, a 17-year-old adolescent, was present at this group session but did not contribute to the project. She was in the art group 12 weeks, but was only able to make a plaque and a rock for another group project. She was admitted to the ward after a suicide attempt and severe long-standing arguments with her mother. She was abrasive in her interactions with peers and staff, and was able to reveal little of herself in the art group. However, in individual and family therapy sessions, she gradually became warmer in her interactions and was able to return home with her mother and earn her high school diploma. GROUP PROJECT This group pists’ anxieties feelings, rather the group of
“ATTEMPTED
ESCAPE”
project probably reflected the theraand attempts to deal with their own than a spontaneous production from adolescents. The community meeting
ART WORK: ANOTHER DIMENSION IN THE TREATMENT OF PSYCHIATRiC PATIENTS
75
Fig. 3 prior to this group had been tense, since one of the members of the group (Mario) had been readmitted involuntarily during a second psychotic episode. During the art session Mario became agitated and suddenly ran out of the room. and tried to run away from the hospital. Two of the other adolescents quickly ran after him and brought him back. He was tense when he returned and the rest of the group was silent. One therapist suggested a group project (Fig. 4) but the patients contributed very un~llingly. One therapist formed a small figure to represent Mario and another who had decided on Mario’s hospitalization formed chains linked to each of the figure’s feet with a rock attached. This tableau probably reflected her own guilty feelings about readmitting him involuntarily. Each therapist also contributed figures offering support to the
chained figure. An o~cupationai therapy student was present during this session and made a figure standing at a distance from the chained figure, which probably meant she didn’t know how to handle the situation. Two of the patients, Ron and Kevin, contributed heads which they identified as Len, a loved and trusted staff member, and said maybe he could help Mario. The other group members did not contribute to the project. The therapists were anxious and frightened by Mario’s unexpected runaway attempt and the entire staff was discouraged by his need for readmission. Neither the patients nor the staff could accept his decompensation and the project probably reflected a need to put an interpersonal distance between his terror and our feelings of failure and discouragement.
76
POWERS AND LANGWORTHY
Fig. 4
CASE REPORT:
TRACI
Traci is a I3-year-old black female with the diagnosis of Anorexia Nervosa, admitted to the hospital after two years of progressive weight loss from 1 IO lbs. to 80 lbs. and a height gain of 2 inches from 5’2” to 5’4”. During the year prior to admission she refused to attend school and remained in her room watching television; her mother brought food to her room, most of which she refused to eat. She spoke little to anyone except her mother and then would whisper in her mother’s ear. She vomited daily, probably abused laxatives, and had bulimic episodes, eating large quantities of food voraciously. The parents were very poor historians but probably she had been amenorrheic for several months. At the time of admission she was initially clinging to her mother and uncommunicative. When her mother left the ward she laid curled in a fetal position and vomited into the cushions of the day room couches. She was with bradycardia. had hypotensive emaciated, ianugo, and a metabolic imbalance. She was initially treated with intravenous fluids to restore metabolic balance. Other causes of weight loss were ruled out. She was started on a behavior modification pro-
gram, with visitors and home passes contingent on weight gain. She was seen by her individual psychotherapist three or more times weekly. She was a member of a therapeutic community and also attended the art group. Her initial work in art therapy began with plaques and hollow bowls which we thought reflected both her sense of emptiness and her lack of depth in interpersonal interactions. She remained non-verbal in the group and on the ward. She gained several pounds but then appeared to be hallucinating. At this time she made an object that appeared to be tangled coils which may have symbolized ego defects. During this period, she was started on a brief course of a low dose of phenothiazines. During the next session she suddenly formed her entire name out of clay and a rose (Fig. 5); we postulated that her sense of identity was beginning to emerge. During the next session she worked with paints, and smeared many layers of paint, mixed up various colors, and wore out the paper on one painting because she used so many coats. She was criticized by her peers for ruining several jars of paint and finally stopped smearing paint; at the same time, she was refusing to gain weight. was hoarding food in her room and refused
ART WORK: ANOTHER
DIMENSION IN THE TREATMENT
OF PSYCHIATRIC
PATIENTS
77
Fig. 5 to speak to the staff, although she was beginning to talk to her peers. She was negativistic, withholding, and in the anal stage of development. In the next session she formed several more plaques, a bead, and finally a bowl which said “hello” on the outside; this bowl may have reflected beginning superficial involvement with her peers. It was also during this time that she made the “Slim Jills” for the circus, which was likely a negative response to being asked to form a plaque. In the next session she made a bowl which fell apart after one of the staff suggested that it needed to be slightly wetter and she added several cups of water to it. In later sessions she formed a grotesque head with bloated cheeks (Fig. 6) which she later glazed white rather than black. She was very interested in this work and later asked several times to take it home with her. It was thought to be another step toward gaining a sense of identity, albeit with a grossly distorted body image. A peer commented on her glazing it white and asked her if she wanted to be white rather than black; she did not answer. At about this time she ran away with this peer who was also the group leader of the adolescents. Traci ran to her cousin’s home, rather than to her parents’ home. Her parents brought her back to the hospital but tricked her, saying they were bringing
her back to get her clothes and while she was in her room they left by the elevator. Soon after that she made a series of strange forms (Fig. 7) and began talking more with peers and staff members. These forms may have represented her feelings of being closed in and dependent_ She had been very interested in her art work, glazing most of it and taking it all home with her when she was discharged. She was discharged soon, talking and laughing with the staff and patients and weighing 117 lbs. Her art work was one of the most heipful aspects of the treatment program, since she was interested in using the clay and asked what the therapists thought her work meant. DISCUSSION The art work of the in~vidual patient is illustrative of her major psychodynamic trends. She was nonverbal initially and art was a medium which allowed the therapists a glimpse of her intrapsychic conflicts. For children, play therapy is known to be an effective method of understanding psychodynamics, and for adolescents art serves the same function while utilizing’an age-appropriate medium. Just as play therapy aims at helping the child act out conflicts in play, and guides the child to resolu-
78
POWERS AND LANGWORTHY
Fig. 6
Fig. 7
ART WORK:
ANOTHER
DIMENSION
IN THE TREATMENT
tion by judicious use of verbal interpretation, so art work serves the same purpose for the adolescent. The adolescent is still in a stage of cognitive development with disequilibrium between thought and feeling, and art can facilitate an integration. The art work is useful only when understood in terms of the entire social situation, including interpersonal relationships with peers, family, therapists and the larger social network. The experience of the group per se may be therapeutic, but its full impact in terms of a holistic treatment program requires careful comprehensive communication to the rest of the team. The work of the therapists is discussed because each therapist reacts to the problems of the patient and each patient reacts to the problems of the therapist. For example, in the second group project “Attempted Escape,” the fears and anxieties of the therapists prompted the project and inhibited the spontaneous response of the remaining group members. The responses of both therapists to Louis and his work probably reflect fears of their own violence and their own capacity for psychosis.
OF PSYCHIATRIC
PATIENTS
79
The group projects reflected the process of interaction between group members, as well as the intrapsychic dynamics of each individual. The art group was one part of a comprehensive treatment program on an inpatient adolescent ward utilizing a social psychiatric therapeutic community, individual and family therapy, group therapy, occupational therapy, and recreational therapy. The work of each group member reflected his own progress in therapy, but use of art as a mode of treatment was most helpful with relatively non-verbal patients who were able to accept and utilize the interpretations of their work in the context of their entire life situation.
REFERENCES CARLETON,
J ., “Social psychiatry,”
to appear in Inter-
national encyclopedia of neurology, psychiatry, psychoanalysis, and psychology, B. B. Wolman, M.D., Editor in
Chief, Jules Masserman, M.D., Editor of Division of Psychiatry. MASTERSON, 1. (1972) Treatment of the borderline adolescent: A developmental approach. New York: Wiley.
Psychotherapy,
Vol. 5 pp. 71-79.
Pergamon Press, 1978.
Printed
in
the U.S.A.
ART WORK: ANOTHER DIMENSION IN THE TREATMENT OF PSYCHIATRIC PATIENTS* PAULINE S. POWERS, M.D. University of South Florida College of Medicine JOY LANGWORTHY, O.T.R. Veterans Administration Hospital Tampa, Florida Art work, as an integral part of a holistic treatment program, reflects the changes a person makes in therapy, and is also a medium which promotes the individual’s awareness of his own feelings and interactions with others so that he may choose whether or not to change. Art work can also facilitate change in therapy. Four major principles of Social Psychiatry are mherent in the interpretations of the art work to be described. These principles include the following: (1) Every person should be the subject and not the object of an interaction. (2) What one person does affects those around him. (3) No problem can be solved without the involvement and contribution of all fields, including medicine, social work, architecture, education, and research. (4) Isolated information about any person becomes meaningful only when incorporated into the total fabric of that person’s life (Carleton). Two group projects to which ail members contributed wiIl be shown and discussed in terms of the group process which culminated in each project. Each individual’s unique contribution to the group project and the relevance this contribution has .in terms of his personality structure, role in the group, and current psychotherapeutic changes, will be discussed. The group projects also reflect attitudes and events in the larger therapeutic community or in other areas of the social network impinging on the art group and its members. Also a detailed description of the course of treatment for one patient will
be presented, utilizing photographs of her art work to hi~i~t the discussion. GROUP PROJECT: “THE CIRCUS” The Circus (Fig. 1) was a project done by a group of adolescents in short-term therapy (3-6 months). All were hospitalized at the time of this project. Two therapists and one medical student also contributed to the project. The hospital setting is a therapeutic comm~i~ designed to encompass the principles of sociJ psychiatry. At the time of this work most of the patients had been hospitaiized at least a month. The major intrapsychic problems of each patient had been identified. Only one patient was near discharge and there was a sense of cohesiveness on the ward. Just prior to the therapy session there had been a community meeting during which several members (patients and staff) complained of being overweight. One of the staff members suggested forming a weight reduction group and the patients enthusiastically elaborated on the idea with the resultant plan that several patients and staff would meet each other for lunch in the communal dining room, encourage one another not to eat, and they agreed that one of the patients (not in the art grtiup) would chart daily weights. The community meeting ended in a spirit of cooperativeness and several people including patients, two janitors, and members of the clinical staff began weight charts. Shortly thereafter the art group began. Ini-
*Requests for reprints should be sent to Pauline S. Powers, M.D., Assistant Professor of Psychiatry, University of South Florida College of Medicine, 12901 North 30th Street, Tampa, Florida 33612. 0090-9092178/0407-007SO2.00/0
Copyright 0 1978Pergamon Press, Inc.
POWERS AND LANGWORTHY
72
Fig. 1 tially there was much talking and laughing about the weight plan and wondering what to do in the art group. One of the therapists suggested a group project and another member suggested a circus. The group was cohesive, and the mood of cooperation doubtless reflected the general mood of the larger therapeutic community. Throughout the art group there was warm lighthearted interaction among the members. Production of the project also helped improve cohesiveness in the group and underscored the feeling of warmth and intimacy prevailing in the larger social network. The follo~ng is a description of each indi~du~‘s contribution to the art group and the relevance it has to each person’s personality characteristics and group role. The cage for the animals in the Circus, the ramp and some of the wheels were constructed by one of the co-therapists, who was also Director of the Adolescent Unit which forms the larger therapeutic community. She initiated the project and felt responsible for providing the support system. It was originally meant to be a wagon but turned out to be a cage and she suspects it reflects her ambivalence toward the involuntary hospitalization of most of these adolescents (many are hospitalized by their parents or the court for treatment) and the difficulty in providing adequate protection for the
adolescent without “caging him in” and permitting the youngster sufficient autonomy to develop a sense of identity. This therapist probably also unrealistically saw herself as the major support system for the therapeutic community, the art group, and her family and responsible “for getting the show on the road” in all these areas. Sybil formed a large, slightly distorted rabbit with whiskers and put the rabbit in the cage. Sybil is a IS-year-old adolescent with a three-year history of drug abuse, frequent runaways, shoplifting and forgery. When Sybil was a toddler she did not know her father, and her mother was often emotionally unavailable, usually drinking or moving the family from place to place. When Sybil was about 4, her mother formed a lasting attachment with a boyfriend who spent much time with the family. The boyfriend died when Sybil was 10 and she and her mother stopped communicating. Sybil began a series of acting-out behaviors which probably reflected an unresolved grief reaction. The diagnostic impression was that she had a borderiine person~ity with insufficient individuation and separation from her mother, and that the loss of the boyfriend who served as a pseudo-stepfather triggered the dramatic acting-out behavior. The treatment plan (Masterson, 1972) was to (1) initially prevent acting-out be-
ART WORK:
ANOTHER
DIMENSION IN THE TREATMENT
OF PSYCHIATRIC
PATIENTS
73
Fig. 2 havior in a structured environment, (2) then to help her connect her behavior and subjective feeling state, (3) then traditional insight psychotherapy focusing on her rage and depression about her mother’s emotional distance, rekindled with the loss of her pseudo-stepfather. The art group was but one aspect of a holistic treatment program designed with this psychodynamic formulation in mind. Initially, in treatment, her work was two-dimensional including a human figure (Fig. 2) and a flat elephant which she described as herself. Early in the second phase of treatment, she formed a distorted human figure in a coffin and soon after formed the rabbit which was part of the circus. She asked th.e therapist what the rabbit meant and the therapist responded that “rabbits run”; she then said that she wanted the staff to put her on escape precautions
and talked about her anger about the possibility of a foster home (which would have represented another loss). Probably the rabbit symbolized her desire to run from her feelings. Sybil also formed a large frog’s head for the circus which she perched on the edge of the cage and she also formed a snake which she put on the ramp. She talked little about these animals but the frog is watchful and may represent a critical superego and the snake may represent the covert, sneaky, unacceptable part of herself. Ron contributed two wheels, copied Sybil’s snake and made a sign for the circus saying “fat asses”. He is a 13-year-old adolescent with a number of difficulties with the police, including running away, breaking and entering, and destroying property in his father’s home. His course on the ward
74
POWERSANDLANGWORTHY
was stormy with many violent agitated episodes occurring consistently after his father’s lack of participation in family therapy. He was also very susceptible to peer pressure and agreed to almost anything the other youngsters planned. His work throughout the art group was often imitative. He was thought to have very fluid ego boundaries and this was reflected in his art work. Despite his angry flare-ups, he was an affectionate youngster, wellliked by staff and patients but unable to express his affection openly. His sign “fat asses” was formed in a good-natured mood and probably reflects his difficulty in admitting any warm feelings. Kevin, a 14-year-old boy, contributed a small bird sitting on the edge of the cage. Kevin was a shy, withdrawn youngster with the diagnosis of schizoid personality. At the time of this project, Kevin was often on the edge of the art group, both emotionally and physically, sometimes moving his chair slightly away from the group, talking little to other group members. Louis was 17 at the time he contributed a small smirking head to the circus. He was admitted to the hospital in an acute psychotic episode with staring, posturing and paranoid ideation. He began art therapy a month after he was admitted and initially made several unusual flowing forms which he said “were neither one thing nor the other” and which we thought were very representative of his weak ego boundaries and vague, ill-defined sense of self. In one session he made a very realistic skull, remarking that he would like to tear the skin off the face of one therapist, because she had not agreed to a pass for the weekend during an earlier community meeting. Later he couldn’t remember he had ever been angry. In this session he spontaneously contributed the small head. The rest of the work he did in clay was flowing, abstract, and non-structured, some of which looked vaguely like human figures and one in particular looked like a monk (Fig. 3). The therapists’ reactions to this youngster were interesting. Neither of us could remember his name after he was discharged even though he had been hospitalized several months; we didn’t take pictures of all his work separately. When we were preparing an exhibit of several of the adolescents’ work, we initially forgot he had contributed anything to the circus. The other therapist contributed the elephant and said elephants were always associated with happiness in childhood. She is, however, quite thin and has difficulty gaining weight and thought her contribu-
tion represented her desire to belong to the group. even though she was very aware of her thinness. Traci is a 13-year-old black female with Anorexia Nervosa, whose work is described in the subsequent case report. By the time of this project she had gained 15 pounds but was still markedly underweight and was very angry; she expressed her anger on the ward by passive-aggressive .means (for example, by vomiting into the pillows in the day room). Her contribution to the project was made only after prompting by several members of the group who suggested a plaque entitled “Slim Gyms”. She made a plaque entitled “Slim Jills” and this was thought to be another angry response to being told what to do and probably also reflected her anger at not being part of the weight-reduction group that had formed on the ward. Brian, a 22-year-old medical student taking part of his training with the adolescent unit, made several animals for the project, including a group of three animals and the hippopotamus. His first work in the art group in an earlier session was of an arm protectively extended. Most of his other contributions were warm, comforting figures. He was very comfortable in this cohesive group session, but in other sessions made figures or projects to produce cohesion or eliminate conflict. This was his pattern in ward interactions as well, where he often assumed the role of a peacemaker or mediator and was very uncomfortable with angry feelings and did not reveal his own anger. Sarah, a 17-year-old adolescent, was present at this group session but did not contribute to the project. She was in the art group 12 weeks, but was only able to make a plaque and a rock for another group project. She was admitted to the ward after a suicide attempt and severe long-standing arguments with her mother. She was abrasive in her interactions with peers and staff, and was able to reveal little of herself in the art group. However, in individual and family therapy sessions, she gradually became warmer in her interactions and was able to return home with her mother and earn her high school diploma. GROUP PROJECT This group pists’ anxieties feelings, rather the group of
“ATTEMPTED
ESCAPE”
project probably reflected the theraand attempts to deal with their own than a spontaneous production from adolescents. The community meeting
ART WORK: ANOTHER DIMENSION IN THE TREATMENT OF PSYCHIATRiC PATIENTS
75
Fig. 3 prior to this group had been tense, since one of the members of the group (Mario) had been readmitted involuntarily during a second psychotic episode. During the art session Mario became agitated and suddenly ran out of the room. and tried to run away from the hospital. Two of the other adolescents quickly ran after him and brought him back. He was tense when he returned and the rest of the group was silent. One therapist suggested a group project (Fig. 4) but the patients contributed very un~llingly. One therapist formed a small figure to represent Mario and another who had decided on Mario’s hospitalization formed chains linked to each of the figure’s feet with a rock attached. This tableau probably reflected her own guilty feelings about readmitting him involuntarily. Each therapist also contributed figures offering support to the
chained figure. An o~cupationai therapy student was present during this session and made a figure standing at a distance from the chained figure, which probably meant she didn’t know how to handle the situation. Two of the patients, Ron and Kevin, contributed heads which they identified as Len, a loved and trusted staff member, and said maybe he could help Mario. The other group members did not contribute to the project. The therapists were anxious and frightened by Mario’s unexpected runaway attempt and the entire staff was discouraged by his need for readmission. Neither the patients nor the staff could accept his decompensation and the project probably reflected a need to put an interpersonal distance between his terror and our feelings of failure and discouragement.
76
POWERS AND LANGWORTHY
Fig. 4
CASE REPORT:
TRACI
Traci is a I3-year-old black female with the diagnosis of Anorexia Nervosa, admitted to the hospital after two years of progressive weight loss from 1 IO lbs. to 80 lbs. and a height gain of 2 inches from 5’2” to 5’4”. During the year prior to admission she refused to attend school and remained in her room watching television; her mother brought food to her room, most of which she refused to eat. She spoke little to anyone except her mother and then would whisper in her mother’s ear. She vomited daily, probably abused laxatives, and had bulimic episodes, eating large quantities of food voraciously. The parents were very poor historians but probably she had been amenorrheic for several months. At the time of admission she was initially clinging to her mother and uncommunicative. When her mother left the ward she laid curled in a fetal position and vomited into the cushions of the day room couches. She was with bradycardia. had hypotensive emaciated, ianugo, and a metabolic imbalance. She was initially treated with intravenous fluids to restore metabolic balance. Other causes of weight loss were ruled out. She was started on a behavior modification pro-
gram, with visitors and home passes contingent on weight gain. She was seen by her individual psychotherapist three or more times weekly. She was a member of a therapeutic community and also attended the art group. Her initial work in art therapy began with plaques and hollow bowls which we thought reflected both her sense of emptiness and her lack of depth in interpersonal interactions. She remained non-verbal in the group and on the ward. She gained several pounds but then appeared to be hallucinating. At this time she made an object that appeared to be tangled coils which may have symbolized ego defects. During this period, she was started on a brief course of a low dose of phenothiazines. During the next session she suddenly formed her entire name out of clay and a rose (Fig. 5); we postulated that her sense of identity was beginning to emerge. During the next session she worked with paints, and smeared many layers of paint, mixed up various colors, and wore out the paper on one painting because she used so many coats. She was criticized by her peers for ruining several jars of paint and finally stopped smearing paint; at the same time, she was refusing to gain weight. was hoarding food in her room and refused
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Fig. 5 to speak to the staff, although she was beginning to talk to her peers. She was negativistic, withholding, and in the anal stage of development. In the next session she formed several more plaques, a bead, and finally a bowl which said “hello” on the outside; this bowl may have reflected beginning superficial involvement with her peers. It was also during this time that she made the “Slim Jills” for the circus, which was likely a negative response to being asked to form a plaque. In the next session she made a bowl which fell apart after one of the staff suggested that it needed to be slightly wetter and she added several cups of water to it. In later sessions she formed a grotesque head with bloated cheeks (Fig. 6) which she later glazed white rather than black. She was very interested in this work and later asked several times to take it home with her. It was thought to be another step toward gaining a sense of identity, albeit with a grossly distorted body image. A peer commented on her glazing it white and asked her if she wanted to be white rather than black; she did not answer. At about this time she ran away with this peer who was also the group leader of the adolescents. Traci ran to her cousin’s home, rather than to her parents’ home. Her parents brought her back to the hospital but tricked her, saying they were bringing
her back to get her clothes and while she was in her room they left by the elevator. Soon after that she made a series of strange forms (Fig. 7) and began talking more with peers and staff members. These forms may have represented her feelings of being closed in and dependent_ She had been very interested in her art work, glazing most of it and taking it all home with her when she was discharged. She was discharged soon, talking and laughing with the staff and patients and weighing 117 lbs. Her art work was one of the most heipful aspects of the treatment program, since she was interested in using the clay and asked what the therapists thought her work meant. DISCUSSION The art work of the in~vidual patient is illustrative of her major psychodynamic trends. She was nonverbal initially and art was a medium which allowed the therapists a glimpse of her intrapsychic conflicts. For children, play therapy is known to be an effective method of understanding psychodynamics, and for adolescents art serves the same function while utilizing’an age-appropriate medium. Just as play therapy aims at helping the child act out conflicts in play, and guides the child to resolu-
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Fig. 6
Fig. 7
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tion by judicious use of verbal interpretation, so art work serves the same purpose for the adolescent. The adolescent is still in a stage of cognitive development with disequilibrium between thought and feeling, and art can facilitate an integration. The art work is useful only when understood in terms of the entire social situation, including interpersonal relationships with peers, family, therapists and the larger social network. The experience of the group per se may be therapeutic, but its full impact in terms of a holistic treatment program requires careful comprehensive communication to the rest of the team. The work of the therapists is discussed because each therapist reacts to the problems of the patient and each patient reacts to the problems of the therapist. For example, in the second group project “Attempted Escape,” the fears and anxieties of the therapists prompted the project and inhibited the spontaneous response of the remaining group members. The responses of both therapists to Louis and his work probably reflect fears of their own violence and their own capacity for psychosis.
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The group projects reflected the process of interaction between group members, as well as the intrapsychic dynamics of each individual. The art group was one part of a comprehensive treatment program on an inpatient adolescent ward utilizing a social psychiatric therapeutic community, individual and family therapy, group therapy, occupational therapy, and recreational therapy. The work of each group member reflected his own progress in therapy, but use of art as a mode of treatment was most helpful with relatively non-verbal patients who were able to accept and utilize the interpretations of their work in the context of their entire life situation.
REFERENCES CARLETON,
J ., “Social psychiatry,”
to appear in Inter-
national encyclopedia of neurology, psychiatry, psychoanalysis, and psychology, B. B. Wolman, M.D., Editor in
Chief, Jules Masserman, M.D., Editor of Division of Psychiatry. MASTERSON, 1. (1972) Treatment of the borderline adolescent: A developmental approach. New York: Wiley.