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The graphic representation of regression in an Alzheimer's disease patient
THE GRAPHIC
REPRESENTXTIOS
ALZHElhlER‘S
Susie vvas a fifty-eight-i,rar-old woman vvho attended the Burke Rehabilitation Center Keurological Day Treatment Program for two years. She had been referred to Burke’s evaluation service for a faulty memory, which dated back about two years. Her husband had noticed that she vvas repetitive, often lost things at home, and forgot appointments. The evaluation team diagnosed her as having Alzheimer-type dementia. and recommended that she attend our Day Hospital Treatment Program. Alzheimer’s disease is a progressive, presenile dementia whose onset occurs before age sixtyt?ve. It is a chronic. irreversible organic brain syndrome.
a progressive
mental deterioration characterizrd hy disorientation and failure in memory and intclkt. If thel-r is cbidence of disorganization of perionalit!, and failure in common activities of dail! life, the condition is considered to represent an organic mental syndroms \vith psychosis constituting the mow severe form of dementia. (Kwasu LYCKatzman. 1976. p. 126)
Organically. it is characterized by atrophy of the brain, loss of neurons. cortical atrophy. neurofibrillary~ tangles. granulovascular changes. and senile plaques. Through Susie. v.‘e follow the behavioral characteristics of the progression of Alzheimer’s disease. In particular, through her artwork. vve foilow her regression and intrapsychic reactions to the degenerative effects of this neuropathological disease, which usually leads to death within five years of diagnosis.
OF REGRESSIOS
DISEASE
IN A>
PATIENT+
PERSON,4L
HISTORY
Susie was born in LIinnesota. She studied drama in college. after which she entertained the troops in Europe through the agency of the United States government. Her mother died of carcinoma or tuberculosis when Susie vvas in college. and some years later her father died of carcinoma. Her grandmother was a little senile at age eightv-eight. Susie pursued an acting career in travelI& shows and in Xew York City, then married a lawyer. They had two children.
EARLY STAGES OF ALZHEIMER’S DISE.-\SE When Susie came into our program. she vvas our highest functioning patient. often mistaken for a volunteer. She was pretty. weighed 130 pounds, played tennis. skied, and was able to do her housework and shopping. She v.as independent of spirit and wanted to be included in the planning of her treatment at Burke. as she put it. “to fix up her head.” She drove her car to the program, was friendly, cheerful, livelv, and a help to the other patients. She talked of her loving. extended family. Her main apparent problem was an expressive aphasia, having trouble vvord-finding, but she managed to talk around a forgotten word with circumlocutions to make her point. When she lost her train of thought in mid-sentence, she would confabulate to cover up her memory loss. This confusion of language is an early characteristic of Alzheimer’s disease. Susie participated enthusiastically in all
‘.A rer~seil version of the slide-talk preenration gi\cn b) the author at the 13th annual .Amcricm Ar: Therapy .-lssociation Conference. Philadelphia. PA. October 1982 xxi at the 2nd annual Quebec Art Therapy Cont’crencs. liontreal. February 19Y-l. -Judith ‘A’a!J i\ XI thrrnpi%t at the Burke Rthabilltntton Center. M’hltr Plainx. ivy.
Her first self-portrait was well ewcuted: her face appeared proud. confident. and elegant I Fig. I). Ho~vever. the long neck, disproportionntz arms and confused hands indicated a disparity brt\\zen the mind and the body and the brpinning &,-line; a subtle organic featur2 is evident in the distortion of the body. Small arms coming from the collar \vere erased. indicating further body confusion. U’e can see splitting in thz bottom half of thz picture in the dress: indeed, the ~~~ell-dr-a~~n head could bz construed as representing thz conscious mind, and the aivk\sard body as representing the unconscioub. Her exuberant personality was exprzssed in all her xtwork, ivhich uxs colorful. rich and espansi\r. Her drawings of a series of ilobvers her artistry. Figure 2a 1Figs. la. b) revealed shows her art skill at entry into program. Earl! perseveration appears in the overgrois.th of the plant to till every space. Figure 3-b Lvhich she ~vhimsicnliy sntitlrd “Dancing Tulips” (she ~vas still a good dancer) indicates perseveration in the repeated outlining ot’ the stems and tloxvsrs and the confusing flov,,er on the right. The four tlov:ers could also represent the four mcmbcrs of hrr familv. At this time her expressive behavior- intensified and hrr energy Irvel became very hish. Subie showed gradual decline monthly as \vell as tluctuations in her behasior. .After four month5 in the day hospital treatment program. her orientation to time and day slipped; once she came on the Lvrong day, at times she arrived at Burke hours too early. She began to put on bveight. became more disorganized. and her husband bvas forced to increase his management of their house. She required more cues and reinforcements in everyday tasks. Shcr ~vas getting lost uhile driving her car. After nine months in the program. she deteriorated in other uays-she had increasing difticulty in remembering \vords, apprared disheveled. inappropriately bvore a hen\.y s\veater in hot weather-. Her social behav-
t 5
ior declined: at times shr atrz with her hands. In dance therapy shz \vas 1s~ coordinated. She had trouble follouing directions and sequencing in a ceramics class. A companion ivas hired to keep her bus)- at horns but Susie fired her. Susie’s ceramic \vork bzcamz more chaotic, disorganized. Shz quickly uorked up an elaburate coil bowl, but failed to attach the coils properly. She was irritated by ml suggestions for better \vork in thz coils. Shr chose six colors to glaze the boul, reflecting her o\,errffusivrnzss. In dance and music therapy, she became over11 enthusiastic and wsuall~. suggesti\,e to a male patient she had befriended. Hobvever. she responded to staff cur35 and calmsd doun. Susie continued to e\,idznce rryression in hzr artbvork. In October. she made a wild and beautiful Halloween picture f Fig. 3). at that time appropriatz to the assigned task. but prrseverative. Looking back to the eerie faces, one sccs a pre-
GR.APHIC
REPRESENT,ATlON
vie\v of the later chaotic, frightening pictures. In November, a year after she entered our treatment program. her husband decided that, after several small accidents, she couldn‘t drive anymore. Thereafter she came to the sessions by tnsi or was driven by family members. Though discouraged and embarrassedt she was persistent. and we afI admired her apparent adjustment to her failings. She continued to be inventive and determined in making communications, despite tvord-finding difficulty. In December, Susie”s Christmas drawing (Fig. 4) had an excessively elaborate. confusing tree, with presents, a tennis racket, and cats under it. She tulked to the cats in the picture in a bizarre. childish manner which caused the staff and patients to squirm in discomfort until I finally distracted her. Her collages, which had als~ays been rich, fuff, and well-balanced, became cluttered. Her choice of words in a word collage (“wonder\~ere indeed retlecful.” .-drama. ‘* “delicious”)
OF ALZHEIMER’S
DISE.ASE
tivr of her previous and basic optimism.
Iti-
life style and her enthusiasm
SECOSD
PHASE
A sudden, dramatic change occurred about a year and a half after Susie \vas enrolled in our day treatment program, Her husband called to rc:port that she had the illusion that her reflection in the mirror \c’as another woman: she believed that this other kvoman came to our program in the car trunk because ivhen she looked in the mirror here, she saw the other b~oman. in art therapy, she produced a drawing (Fig, 5) which she entitled “\Iy thetvp-my ladies” (“the\vg” probably mzaning “theory“). beginning the evidencing of her word distortion. The top figure v.as ;f man.5 head and half-torso. The hair, standing on edge. continued into angry strcnks that became larger and larger in the hackground. The funnel-noss and phallic tie indicated
sexual preoccupation. The figure positioned below xvas rounded. more female-i&e, even more distorted. with arms coming out of the head and a neck leading to a heart with eyes in it. indicating regression to a primitive stage of drawing. Two round eye-breasts were on either side of the heart. The outer form was uterus shaped and surrounded by a fringe. like pubic hair. The faces had no mouths, indicative of her failing speech. The transparencies of the upper figure Izig-zag lines looking like ribs). the heart of the second figure, the sexual preoccupation with phallic and vaginal shapes, the lack of mouths, general distortions. and the breast-eyes were the beginning of Susie’s psychotic art vocabulary. The distress one feeis at this picture was expressed by her in group therapy when she cried and said that she felt miserable. Susie now exhibited organic brain syndrome with psychosis, the more severe form of dementia.
GR.APHIC
REPRESE?JXTlOS
From then on her artwork reflected her fears and suffering. xvhich she had so long hidden and denied. She no longer recognized her mirror image. for she no longer looked, felt, or thought like the beautiful. vivacious woman she once was. Actresses often have a high degree of narcissism in their personalities, and to look into the mirror and see what she had become estemally and internally must have been so traumatic that Susie withdraw to a psychotic rationalization. She threw water and toilet paper at the mirror, though still aware enough not to throw a substance that would break the mirror. Her figures were no longer rooted in reality. Human figures began to split into monsters. In an art therapy session a month later. she talked fog the first time about Lvhat she drew. In the first picture (Fig. 6. upper left) she drew a brown dog with two heads and multiple legs. Nest to it she drew an orange figure with red eyes. and outlined the head in red. The ears Lvere big. strange11 pointed. and there wxs confusion in the mouth and nose area. I asked who it was. She said. “a man Lvith big ears. I told him to go away.” How-
OF ALZHEI>lER‘S
DISE_ASE
IV2
ever. the body had a woman’s figure wearing a ckveater. buttons. and skirt, and with strange eq’e “decorations” on the sweater. 1Vas that the “other \voman”‘! The confusion of the nose and mouth and her misidentification of the sex of the figure pointed to sexual confusion. The open hands had sharp. multiple fingers. indicating her aggressive feelings. She then made a Lvell-drakvn figure of a light blue dog. but, noticing that she forgot to connect the legs. corrected the drauing, while saying. “Poor thing. can‘t go on like that” (sq’mbolically reacting to herself). In the next picture (Fig. 6, lower left) of that same art therapy session. Susie drew in blue a lveird figure to the left. She called my attention to the eyes. nose and mouth. Hair or arms were coming out of the head. The legs and feet were colored strongly within the container-like figure. A long phallic-hke shape came from between the legs; 1 asked her what it was and she replied, “You know what it is.” This seemed to reflect a transference regression to a stage of preoedipal symbiotic identification Lvith me as the mother bvho knows what the infant thinks and feels. The extremities contained lvithin the triangular shape with hair-like fringe around it like a vagina was overtly sexual. Then she drew a face with a red crayon. this time clearly a face with strong features reminiscent of her first self-portrait. Legs and feet grew out of the head. The hair was wild and wing-like, she said, “to flv awxy, to ask him \vhy it ~‘as like this. \vh\, this \vas happening. \vhy it wasn’t really good.“ This brought to mind Elisabeth Kubler-Ross‘ theory ( 1979) of the five stages of dying: (1) denial and isolation. (7) anger. (3) bargainins, (4) depression, (5) acceptance. This could be the “bargaining with God” stage, mixed with the anger stage. For her last picture of the session (Fig. 6, right) I asked Susie to draw someone who sat across from her, to see if she could still visually relate to external realitv. She took a white crayon and drew a white hat s-imular to the one worn by the woman who sat across from her. Then she took a red crayon and made w,hat at first appeared to me to be decorations on the hat. When she finished 1 asked her to also make the head. pointing below. She said. “The poor thing has no head. It is a pity,” reacting to her own loss of intellectual functioning. At once I realized that she had made the hat into a frilly dress with but-
tons on a fat, headless woman (Susie herself nou had gained much weight and wore frilly dresses). She then draw a big smiling face under the figure. Around the face and from one foot of the fat, headless body came a curved “path,“ Susie said. “to get away.” On the path she drew a more masculine face with thick eyebrows, no mouth, and then an odd heart-shaped face uith a stick nose and legs, a cat-like tail and ears. The cat-like figure appeared often in Susie‘s configurations. .A vase of flowers placed as a model for a drawing would be transformed on paper into a cat. I recalled her Christmas picture which she drew four months before her psychotic ideations surfaced so overtly, when she talked at length to the cats in her picture. Susie had cats at home; they* -gave her comfort. I remembered that she chose mainly rich. soft textures for a collage. The dance therapist observed that Susie ivas becoming more feline in her movements, dancing in
her fur coat and holding her fingers in claw-like positions. This may reflect her increased identification with cats \vho need cuddling and are nonverbal. She was presenting a mixed set of declining faculties. As Alzheimer’s disease progresses. adaptive mechanisms which depend on memory fail. This can lead to a decline in moral standards. antisocial acts, espressions of sexual or other fantasies. or paranoid thinkin!. “With the loss of advanced intellectual functions. previously sublimated or represxd pathology may come to the fore as the patient loses his defenses” (Karasu S: Katzman, 1976, p. ii 1). Sexual preoccupationphallic shapes. bright lips and hearts-continued to show in her pictures. She had lost her defenses. with the result that primitive sexual fantasies took shape in her pictures and in her dancing. At this time. the ma!e patient with whom she had paired was also in decline and he rebuffed her.
GR,i\PHIC
REPRESEST.ATION
Her flower drawings turned angry, had jagged, clakv-like lines outlined in black. Her sexual. sensual preoccupations were a mixed bay of frustrations. loss of controlling social defense mechanisms, and, even more, expressed a yearning for affection and comfort, and anger at being denied except by her cats and her warm. soft fur coat. The coat made her more desirable-more likely to be touched and cuddled like cats. It also represented regression to a kinesthetic tactile. sensor) perceptive stage of psychosesual development similar to infants whose skin becomes the primary receptive organ receiving pleasurable stimuli. Susie’s self-portraits were a true graphic representation of her disintegration. In the freaky self-portrait with the eye-breast-buttons and multiple cla\v-hands (Fig. 7. left). she revealed how ugly. conspicuous, and helpless she felt. She V.X clearly upset with her drawing. so I assured her that she didn’t look like that, and I would help uith her next drawing. I told her to slowly draw a head. the eyes, etc.. step-by-step. She uas pleased as the face looked more feminine and prettier (Fig. 7, center). However. when she did the hair she continued it around the entire face: she also lost control of the body and that became another internal face. The following week we worked as a group on
OF ALZHEIXIER’S
DISE.lSE
1-I
portraits and I illustrated each feature step-bystep. Susie drew a Picasso-like portrait, more primitive than she had ever produced (Fig. 7. right). We used light colored chalk. Toward the end 01‘ the session I gave the group a dark charcoal and instructed them to use it to emphasize whatever they wished. Susie chose to emphasize the breast-eyes. This symbol of breast-eyes represents a regression to the early stage of oral nurturing-a child nursing at its mother’s breasts and looking up at her eyes. Edith Jacobson points out that “the child’s first visual impressions of the mother are connected with the feeding situation. It is the combined oral-visual experience at the breast . . that not only equates the mother with the breast but turns the latter into the first image of the gratifying mother” ( 1973. p. 35). The multiple buttons also symbolize maternal dependency. .As Alzheimer’s disease progresses, perceptual loss, confusion and agitation can cause body and spatial disorientation. In figure drawings, Susie shoued loss of body concept by omitting and confusing body parts. She \vas losing her dancing ability, becoming more disintegrated in general-her makeup was bizarre. her grooming poor. and her conversation increasingly unintelligible. She bvore a coat indoors (perhaps to hold
Her drakvings wcre intricate and more disturbing. Her monSterS. hnlf-pzopie-~r~arurc~-animlils indicated her ova monStrou5 xlf-image and primitive aggrsssiv2 impulses; th;r numerous t‘yrs indicated paranoia plus ineffxtiysness in dznling kvith the monstrous disease which had taken control of her. Toww-d the end of the summer, she wxs preoccupied bvith ~1trip she and her daughter \vere taking to >finnesota where she grew up% to \,isit old friends and relatives. This seemed to give het something to look forward to and to cliny to in addition to her purse. Despite the fears and anger she prewnted in her dra\\ings. she continued to participate actively in our progmm. THIRD
PH.-\SE
Alzheimer’s disease patients cope bc~i tvhcn there is little change in their environment and few demands are placed on them. Susie wxs no exception. She returned in 3 greatly regressed condition. Z4pparently she had ;t catastrophic reaction to all the strains of her- jout-nr!. Her daughter reported that she v.xs rest&s. irrttatcd. and always Lvanting to Icave relatives and friends. To calm her she tool; St~sie for walks in the ~voods. Hwvcver, Susie told us that her trip bvrnt well. She \vns angry about returning to our program. though she had altsays liksd it before. She acted out, threw her purse and chairs, stomped out of rooms. Her affect was intense: she wxs restless, angry. tearful. Kubler-Ross has described the second stage of d>,ing as anger. It certainly appeared that Susie could no longer deny her degenerative condition and the emotional pain it caused her; nor could she split into tbt’o women, nor r~leasts her anger through art and dance. Now she exhibited rag. From 0111 highest functioning patient of t\vo years ago, Susie \vas no\v our lowest functioning. most difficuli patient. To calm her. shz required tht: personal attention of one or ttvo staff members. Recalling Susie’s love for cats. one staff member showed her a picture of a cat: that caught her attention. hfusic calmed her. and she strummed the auto-
harp xvith the music therapist. To get hzr into art therapy. I plnyzd the ?nchanting “Nutcracker SUik” and had ever)‘one draw a mural to ii. i requested the sraff member bvith Lvhom she felt moSt comfortabk to sit nest to her and begin drawing. Sitsir: finally did drau again, but, in contrast 10 the large. effusive drnv.kgs she used to do on the mur-alj. shr norked in a small qxxr, and produced a tight Iitrle dra\ring with many eyes and colors and staccato, broken lines. When I asked her if I;hc wanted to expand into the empty space on the paper, 51~~ covered her dratving with her purse and said. “So!” Indeed. the denial LX gone. and Susie had entercd into \shat KublerRoss called the fourth stage of dying, namely. loss and depression. One da!’ Susie sat alone on a bench in the hallway. I joined her. and noticed that she had polish on the nails of only ant’ hand. f suggested that we put poii$h on the other nails also. She agreed. and this seemed to reestablish O~JI-reln< tionship. Later in art therapy. 1 set up a basket of ticsh flower\ and suggested that she draw it. Insteal, she produced a drawing of “a friend, a lady.” sht: said. . . . mouthfess, spotted, striped. kvith t\vo hearts. I pointed to the strongly coiored g-sen heart. She made no reply.. I asked if the person had a good heart and she said, ‘-Yes.” She had previouslv spoken glowingly of her daughter as “her f;knd.” Here we see a role wvrrsal in the transference Irith the art therapist instead of the “goud 2s the “good daughttlr“ ‘it-ho understands and would not abanparent” don her. It was her daughter \vho had taken and helped her on the rt’;cnt disastrous trip to Itlinnrsota. Thzrs BYIS a scfnse of depression about the picture. The next wezk in art therapy, Susie produced 3 multicolored picture uith more primitive symbolr than tzvzr (Fig. St. The smiling transparent figure to the right. she said, \vas “A uoman. happ).. becau~r she’s doing it, doing it. she‘s getting what she likes, again and again, 1’011 should knou.“ Kots thz lar!r phallic shape over the vaginal xea. The tiqrr m the upper left. she SuGs said. “was apart, tvatching the situation.” had isolated herself from the group. and no\v ~vas trying to reenter her life here and at home. She drev. a cat in the middle. Other gnome-like figures gr,ith fxccs in their bodies and feet coming
GR.APHIC
REPRESE>Ta%TIOS
from the head resembled the early stage in children.5 drabvings. Her artwork sho\ved extreme regression, primitil-ism and chaos. Reacting to too much loss, she continued to regress to a more primitive level of functioning. Susie continued to be anxious, agitated and tearful, stomping in and out of rooms. and. at one point. sitting on the floor. She ~‘~4s better adjusted at art and dance where she could be creative. She had a hard time sitting still for anything. and at one art therapy session she dashed off (in two minutes) an empty figure, then got up again. This picture \vas in an angr)-. angular style. with dots for breasts and a navel (or the beginning of another internal face). The body was more rectangular than ever, like a retarded person’s dra\ving. In ceramics, she mashed the clay into amorphous volcanic forms and stuck n stick into each. Totally confused. she kept washing her hands
OF ALZHEI>fER’S
DISE.ASE
1-3
in the clay Irater. The volcano-like shape was repeated in painting. She produced a vibrant, explosive acrylic painting (Fig. 9) when I squirted paint on her paper to keep her connected to task and to pet her to espress her agitation through art. It \vas as though the volcanos of the two other artuorks had exploded. Yet. a face appeared within the confusion. Susie‘s pictures became more and more formless as she regressed more and more. Her drauing became more incoherent and disconnected. Lvith perseverative dashes. dots. and loops. and unrelated Lvords. Her faces disintegrated into perseverative. s&cc&o dots, like the constant clicking of her purse latch or tapping of heI fingers (Fig. IO). The body \vas eliminated; she had regressed in her drawing to a circle and rhythms. like n child. However. within the eye was another internal fxe.
Grntiu:~ll~~, LW realized that Susie responded to hugs more than to anything else. We recalled bet drawings of eye-breasts. and realized that primitive orrtt nurturing. like a child nursing at its mother’s breast and looking up ai her eyes, ‘~~‘2sthe greatest need she now had. bctivea her overeating and response to hugs. During the last weeks Susie attended our program. shz ;vas in deep despair. While most of her speech was incoherent and disconntcted, she clearly said, “I’m d>-kg,” “I’m going to die,” “I hurt so much,“’ “I can‘t do anything.” .*lVhat should I do’?” She had difticulry recognizing faces. even her husband‘s, She said she \vas “so tirctd.” and indeed did not sleep ~~11 at night. Tranquilizers and antipsychotic drugs helped iitrle or caused akrtthisia, 3 state of motor rsstkssness. Regressed to a pregenital level of functioning, she sought security and reassurance from the staff. Desperate for affection, she ran from one staffmcmber to another to kiss and hug us. She
CONCLUSiOiL’ 1t?c have folloa~d, in the ewe of Susie. thz courw of Xlzhrimer.\ cliwase ancf the dcvastating effects its degenzratise yu3lities had on her personality structure:. A i-ibrxlt, attractive ~vomnn. a trtiented actress capable of expressing deep emotions, Susi, had. in :I rinse. a longer \vay to fall than the aLerage person. Perhaps that is \\ hq’ her regression \t-a~ so dramatic and severe: perhaps the shock ~35 Freater. It should be stated that the behavior31 an3 clinical course of Xlzheimrr‘s disease vnrirs from case to case, ii intlucnced b> nnci that “the dying process many factors-the s)‘mptoms of thz disease. the personality of the individual, and tht: social en\-ironmtnt” (Cohen et nl. 19S4:. p. 1I ).
GRAPHIC
REPRESENTATION
We have followed the stages of dying, seeing denial, anger, bargaining, loss and depression in Susie, but not always in that order. “Not every dying person manifests five stages, and not every individual with dementia experiences the phases in the [same] order. . . . The psychological stages may be overlapping or concurrent” (Cohen et al, 1984, p. 12). While it was not my intention to prove or disprove Kubler-Ross’ theory, but rather to help clarify the emotions we must note that she Susie experienced. never reached the final more peaceful stage of “acceptance.” The expression of dementia also varies in artwork. In Susie’s art, we saw the organic brain syndrome symptoms of perseveration and disproportion in the early stages of the disease, and the expression of problem areas, concerns. and interests. Throughout we followed the intensity of her affect. Psychotic ideation, a more severe but less common aspect of dementia, was portrayed in the second stage as Alzheimer’s disease advanced. Susie made a powerful statement by denying that the face she saw in the mirror was her own. Her increased confusion of self-image, the difficulty in separating the self from the object, shows the object relation theory in reverse, in particular with her eye-breast images-not knowing where the breast begins or ends, nor where the mother and she begin or end, as in the first primitive experience. As she regressed, we saw Edith Jacobson’s theory of an “undifferentiated matrix” (Blanck & Blanck, 1979, p. 37,) of personality structure at birth in reverse as Susie
OF ALZHEIMER’S
DISEASE
175
approached death: a mixture of ego, id. affect. libidinal drive. aggressive drive was portrayed in her artwork. We were pulled deeper and deeper into the unconscious as she regressed and perseverated with images of faces within faces within faces. In the third phase of her regression, Susie’s artwork became primitive rhythms. fragmented lines, and frantic marks. During her last session in our program, she couldn’t connect enough to pick up a crayon or paintbrush. She died soon thereafter. REFERENCES BLANCK ‘UC BLANCK (1979) E,g” P.s~ci~~~/o,~~ II. New York: Columbia Universtty Press. COHEN. D., KENNEDY. G. R: EISDORFER. C. (1984) Phases ofchange in the patient with Alrheimeis dementia: A conceptual dimension for defining health care management. J(~trr,~trl o/’ rirc ,4//fcric,c1!1 Gf,r&rrics S~xicr~ 32( I ): I l-16. CRONIN, S. s( WERBLOWSKY. J. (1979) Early signs of organicity. ,4,-r I’,~~(-/~,,ri~l,rlr/,~ 6(Z): 10%108. JACOBSON. E. ( 1973) T/r<, Selltrtrtl r/r<, 0hjcc.f \t’t~r[c/. New York: International Universities Press. KARASU. T. L! KATZhl.\?i. R. (1976) Organic brain syndromes. In L. Bellak & T. Karasu (Eds.1, Gcritrrric f’s!ci~ltrrr~. New York: Gruns CY Stratton. Pp. 123-115. KARASU. T. 9: WALTZhl;\N, S. (1976) Dying. death. and funerals. In L. Bellak R: T. Karasu (Eds.). fhid. Pp. 247278. KUBLER-ROSS. E. (1979) O/I fIc,otll cl& L)~if~,q. New York: hlacillillan. LACHMAN-CHAPIN. hl. (1979) Kohut‘s theories on narcissism: Implications for art therapy. r\rrr~rictrjr Joctnlcll o/‘ rtrt 771ertr/‘? 19: 3-9. WALD. J. I 1983) Alzheimer’s disease and the role ofnrt therapy m Its treatment. Afrrrric.trti Jorrrrrril of Arr 7~lrrrtrp~ 22(Z): 5 l-64.
REPRESENTXTIOS
ALZHElhlER‘S
Susie vvas a fifty-eight-i,rar-old woman vvho attended the Burke Rehabilitation Center Keurological Day Treatment Program for two years. She had been referred to Burke’s evaluation service for a faulty memory, which dated back about two years. Her husband had noticed that she vvas repetitive, often lost things at home, and forgot appointments. The evaluation team diagnosed her as having Alzheimer-type dementia. and recommended that she attend our Day Hospital Treatment Program. Alzheimer’s disease is a progressive, presenile dementia whose onset occurs before age sixtyt?ve. It is a chronic. irreversible organic brain syndrome.
a progressive
mental deterioration characterizrd hy disorientation and failure in memory and intclkt. If thel-r is cbidence of disorganization of perionalit!, and failure in common activities of dail! life, the condition is considered to represent an organic mental syndroms \vith psychosis constituting the mow severe form of dementia. (Kwasu LYCKatzman. 1976. p. 126)
Organically. it is characterized by atrophy of the brain, loss of neurons. cortical atrophy. neurofibrillary~ tangles. granulovascular changes. and senile plaques. Through Susie. v.‘e follow the behavioral characteristics of the progression of Alzheimer’s disease. In particular, through her artwork. vve foilow her regression and intrapsychic reactions to the degenerative effects of this neuropathological disease, which usually leads to death within five years of diagnosis.
OF REGRESSIOS
DISEASE
IN A>
PATIENT+
PERSON,4L
HISTORY
Susie was born in LIinnesota. She studied drama in college. after which she entertained the troops in Europe through the agency of the United States government. Her mother died of carcinoma or tuberculosis when Susie vvas in college. and some years later her father died of carcinoma. Her grandmother was a little senile at age eightv-eight. Susie pursued an acting career in travelI& shows and in Xew York City, then married a lawyer. They had two children.
EARLY STAGES OF ALZHEIMER’S DISE.-\SE When Susie came into our program. she vvas our highest functioning patient. often mistaken for a volunteer. She was pretty. weighed 130 pounds, played tennis. skied, and was able to do her housework and shopping. She v.as independent of spirit and wanted to be included in the planning of her treatment at Burke. as she put it. “to fix up her head.” She drove her car to the program, was friendly, cheerful, livelv, and a help to the other patients. She talked of her loving. extended family. Her main apparent problem was an expressive aphasia, having trouble vvord-finding, but she managed to talk around a forgotten word with circumlocutions to make her point. When she lost her train of thought in mid-sentence, she would confabulate to cover up her memory loss. This confusion of language is an early characteristic of Alzheimer’s disease. Susie participated enthusiastically in all
‘.A rer~seil version of the slide-talk preenration gi\cn b) the author at the 13th annual .Amcricm Ar: Therapy .-lssociation Conference. Philadelphia. PA. October 1982 xxi at the 2nd annual Quebec Art Therapy Cont’crencs. liontreal. February 19Y-l. -Judith ‘A’a!J i\ XI thrrnpi%t at the Burke Rthabilltntton Center. M’hltr Plainx. ivy.
Her first self-portrait was well ewcuted: her face appeared proud. confident. and elegant I Fig. I). Ho~vever. the long neck, disproportionntz arms and confused hands indicated a disparity brt\\zen the mind and the body and the brpinning &,-line; a subtle organic featur2 is evident in the distortion of the body. Small arms coming from the collar \vere erased. indicating further body confusion. U’e can see splitting in thz bottom half of thz picture in the dress: indeed, the ~~~ell-dr-a~~n head could bz construed as representing thz conscious mind, and the aivk\sard body as representing the unconscioub. Her exuberant personality was exprzssed in all her xtwork, ivhich uxs colorful. rich and espansi\r. Her drawings of a series of ilobvers her artistry. Figure 2a 1Figs. la. b) revealed shows her art skill at entry into program. Earl! perseveration appears in the overgrois.th of the plant to till every space. Figure 3-b Lvhich she ~vhimsicnliy sntitlrd “Dancing Tulips” (she ~vas still a good dancer) indicates perseveration in the repeated outlining ot’ the stems and tloxvsrs and the confusing flov,,er on the right. The four tlov:ers could also represent the four mcmbcrs of hrr familv. At this time her expressive behavior- intensified and hrr energy Irvel became very hish. Subie showed gradual decline monthly as \vell as tluctuations in her behasior. .After four month5 in the day hospital treatment program. her orientation to time and day slipped; once she came on the Lvrong day, at times she arrived at Burke hours too early. She began to put on bveight. became more disorganized. and her husband bvas forced to increase his management of their house. She required more cues and reinforcements in everyday tasks. Shcr ~vas getting lost uhile driving her car. After nine months in the program. she deteriorated in other uays-she had increasing difticulty in remembering \vords, apprared disheveled. inappropriately bvore a hen\.y s\veater in hot weather-. Her social behav-
t 5
ior declined: at times shr atrz with her hands. In dance therapy shz \vas 1s~ coordinated. She had trouble follouing directions and sequencing in a ceramics class. A companion ivas hired to keep her bus)- at horns but Susie fired her. Susie’s ceramic \vork bzcamz more chaotic, disorganized. Shz quickly uorked up an elaburate coil bowl, but failed to attach the coils properly. She was irritated by ml suggestions for better \vork in thz coils. Shr chose six colors to glaze the boul, reflecting her o\,errffusivrnzss. In dance and music therapy, she became over11 enthusiastic and wsuall~. suggesti\,e to a male patient she had befriended. Hobvever. she responded to staff cur35 and calmsd doun. Susie continued to e\,idznce rryression in hzr artbvork. In October. she made a wild and beautiful Halloween picture f Fig. 3). at that time appropriatz to the assigned task. but prrseverative. Looking back to the eerie faces, one sccs a pre-
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REPRESENT,ATlON
vie\v of the later chaotic, frightening pictures. In November, a year after she entered our treatment program. her husband decided that, after several small accidents, she couldn‘t drive anymore. Thereafter she came to the sessions by tnsi or was driven by family members. Though discouraged and embarrassedt she was persistent. and we afI admired her apparent adjustment to her failings. She continued to be inventive and determined in making communications, despite tvord-finding difficulty. In December, Susie”s Christmas drawing (Fig. 4) had an excessively elaborate. confusing tree, with presents, a tennis racket, and cats under it. She tulked to the cats in the picture in a bizarre. childish manner which caused the staff and patients to squirm in discomfort until I finally distracted her. Her collages, which had als~ays been rich, fuff, and well-balanced, became cluttered. Her choice of words in a word collage (“wonder\~ere indeed retlecful.” .-drama. ‘* “delicious”)
OF ALZHEIMER’S
DISE.ASE
tivr of her previous and basic optimism.
Iti-
life style and her enthusiasm
SECOSD
PHASE
A sudden, dramatic change occurred about a year and a half after Susie \vas enrolled in our day treatment program, Her husband called to rc:port that she had the illusion that her reflection in the mirror \c’as another woman: she believed that this other kvoman came to our program in the car trunk because ivhen she looked in the mirror here, she saw the other b~oman. in art therapy, she produced a drawing (Fig, 5) which she entitled “\Iy thetvp-my ladies” (“the\vg” probably mzaning “theory“). beginning the evidencing of her word distortion. The top figure v.as ;f man.5 head and half-torso. The hair, standing on edge. continued into angry strcnks that became larger and larger in the hackground. The funnel-noss and phallic tie indicated
sexual preoccupation. The figure positioned below xvas rounded. more female-i&e, even more distorted. with arms coming out of the head and a neck leading to a heart with eyes in it. indicating regression to a primitive stage of drawing. Two round eye-breasts were on either side of the heart. The outer form was uterus shaped and surrounded by a fringe. like pubic hair. The faces had no mouths, indicative of her failing speech. The transparencies of the upper figure Izig-zag lines looking like ribs). the heart of the second figure, the sexual preoccupation with phallic and vaginal shapes, the lack of mouths, general distortions. and the breast-eyes were the beginning of Susie’s psychotic art vocabulary. The distress one feeis at this picture was expressed by her in group therapy when she cried and said that she felt miserable. Susie now exhibited organic brain syndrome with psychosis, the more severe form of dementia.
GR.APHIC
REPRESE?JXTlOS
From then on her artwork reflected her fears and suffering. xvhich she had so long hidden and denied. She no longer recognized her mirror image. for she no longer looked, felt, or thought like the beautiful. vivacious woman she once was. Actresses often have a high degree of narcissism in their personalities, and to look into the mirror and see what she had become estemally and internally must have been so traumatic that Susie withdraw to a psychotic rationalization. She threw water and toilet paper at the mirror, though still aware enough not to throw a substance that would break the mirror. Her figures were no longer rooted in reality. Human figures began to split into monsters. In an art therapy session a month later. she talked fog the first time about Lvhat she drew. In the first picture (Fig. 6. upper left) she drew a brown dog with two heads and multiple legs. Nest to it she drew an orange figure with red eyes. and outlined the head in red. The ears Lvere big. strange11 pointed. and there wxs confusion in the mouth and nose area. I asked who it was. She said. “a man Lvith big ears. I told him to go away.” How-
OF ALZHEI>lER‘S
DISE_ASE
IV2
ever. the body had a woman’s figure wearing a ckveater. buttons. and skirt, and with strange eq’e “decorations” on the sweater. 1Vas that the “other \voman”‘! The confusion of the nose and mouth and her misidentification of the sex of the figure pointed to sexual confusion. The open hands had sharp. multiple fingers. indicating her aggressive feelings. She then made a Lvell-drakvn figure of a light blue dog. but, noticing that she forgot to connect the legs. corrected the drauing, while saying. “Poor thing. can‘t go on like that” (sq’mbolically reacting to herself). In the next picture (Fig. 6, lower left) of that same art therapy session. Susie drew in blue a lveird figure to the left. She called my attention to the eyes. nose and mouth. Hair or arms were coming out of the head. The legs and feet were colored strongly within the container-like figure. A long phallic-hke shape came from between the legs; 1 asked her what it was and she replied, “You know what it is.” This seemed to reflect a transference regression to a stage of preoedipal symbiotic identification Lvith me as the mother bvho knows what the infant thinks and feels. The extremities contained lvithin the triangular shape with hair-like fringe around it like a vagina was overtly sexual. Then she drew a face with a red crayon. this time clearly a face with strong features reminiscent of her first self-portrait. Legs and feet grew out of the head. The hair was wild and wing-like, she said, “to flv awxy, to ask him \vhy it ~‘as like this. \vh\, this \vas happening. \vhy it wasn’t really good.“ This brought to mind Elisabeth Kubler-Ross‘ theory ( 1979) of the five stages of dying: (1) denial and isolation. (7) anger. (3) bargainins, (4) depression, (5) acceptance. This could be the “bargaining with God” stage, mixed with the anger stage. For her last picture of the session (Fig. 6, right) I asked Susie to draw someone who sat across from her, to see if she could still visually relate to external realitv. She took a white crayon and drew a white hat s-imular to the one worn by the woman who sat across from her. Then she took a red crayon and made w,hat at first appeared to me to be decorations on the hat. When she finished 1 asked her to also make the head. pointing below. She said. “The poor thing has no head. It is a pity,” reacting to her own loss of intellectual functioning. At once I realized that she had made the hat into a frilly dress with but-
tons on a fat, headless woman (Susie herself nou had gained much weight and wore frilly dresses). She then draw a big smiling face under the figure. Around the face and from one foot of the fat, headless body came a curved “path,“ Susie said. “to get away.” On the path she drew a more masculine face with thick eyebrows, no mouth, and then an odd heart-shaped face uith a stick nose and legs, a cat-like tail and ears. The cat-like figure appeared often in Susie‘s configurations. .A vase of flowers placed as a model for a drawing would be transformed on paper into a cat. I recalled her Christmas picture which she drew four months before her psychotic ideations surfaced so overtly, when she talked at length to the cats in her picture. Susie had cats at home; they* -gave her comfort. I remembered that she chose mainly rich. soft textures for a collage. The dance therapist observed that Susie ivas becoming more feline in her movements, dancing in
her fur coat and holding her fingers in claw-like positions. This may reflect her increased identification with cats \vho need cuddling and are nonverbal. She was presenting a mixed set of declining faculties. As Alzheimer’s disease progresses. adaptive mechanisms which depend on memory fail. This can lead to a decline in moral standards. antisocial acts, espressions of sexual or other fantasies. or paranoid thinkin!. “With the loss of advanced intellectual functions. previously sublimated or represxd pathology may come to the fore as the patient loses his defenses” (Karasu S: Katzman, 1976, p. ii 1). Sexual preoccupationphallic shapes. bright lips and hearts-continued to show in her pictures. She had lost her defenses. with the result that primitive sexual fantasies took shape in her pictures and in her dancing. At this time. the ma!e patient with whom she had paired was also in decline and he rebuffed her.
GR,i\PHIC
REPRESEST.ATION
Her flower drawings turned angry, had jagged, clakv-like lines outlined in black. Her sexual. sensual preoccupations were a mixed bay of frustrations. loss of controlling social defense mechanisms, and, even more, expressed a yearning for affection and comfort, and anger at being denied except by her cats and her warm. soft fur coat. The coat made her more desirable-more likely to be touched and cuddled like cats. It also represented regression to a kinesthetic tactile. sensor) perceptive stage of psychosesual development similar to infants whose skin becomes the primary receptive organ receiving pleasurable stimuli. Susie’s self-portraits were a true graphic representation of her disintegration. In the freaky self-portrait with the eye-breast-buttons and multiple cla\v-hands (Fig. 7. left). she revealed how ugly. conspicuous, and helpless she felt. She V.X clearly upset with her drawing. so I assured her that she didn’t look like that, and I would help uith her next drawing. I told her to slowly draw a head. the eyes, etc.. step-by-step. She uas pleased as the face looked more feminine and prettier (Fig. 7, center). However. when she did the hair she continued it around the entire face: she also lost control of the body and that became another internal face. The following week we worked as a group on
OF ALZHEIXIER’S
DISE.lSE
1-I
portraits and I illustrated each feature step-bystep. Susie drew a Picasso-like portrait, more primitive than she had ever produced (Fig. 7. right). We used light colored chalk. Toward the end 01‘ the session I gave the group a dark charcoal and instructed them to use it to emphasize whatever they wished. Susie chose to emphasize the breast-eyes. This symbol of breast-eyes represents a regression to the early stage of oral nurturing-a child nursing at its mother’s breasts and looking up at her eyes. Edith Jacobson points out that “the child’s first visual impressions of the mother are connected with the feeding situation. It is the combined oral-visual experience at the breast . . that not only equates the mother with the breast but turns the latter into the first image of the gratifying mother” ( 1973. p. 35). The multiple buttons also symbolize maternal dependency. .As Alzheimer’s disease progresses, perceptual loss, confusion and agitation can cause body and spatial disorientation. In figure drawings, Susie shoued loss of body concept by omitting and confusing body parts. She \vas losing her dancing ability, becoming more disintegrated in general-her makeup was bizarre. her grooming poor. and her conversation increasingly unintelligible. She bvore a coat indoors (perhaps to hold
Her drakvings wcre intricate and more disturbing. Her monSterS. hnlf-pzopie-~r~arurc~-animlils indicated her ova monStrou5 xlf-image and primitive aggrsssiv2 impulses; th;r numerous t‘yrs indicated paranoia plus ineffxtiysness in dznling kvith the monstrous disease which had taken control of her. Toww-d the end of the summer, she wxs preoccupied bvith ~1trip she and her daughter \vere taking to >finnesota where she grew up% to \,isit old friends and relatives. This seemed to give het something to look forward to and to cliny to in addition to her purse. Despite the fears and anger she prewnted in her dra\\ings. she continued to participate actively in our progmm. THIRD
PH.-\SE
Alzheimer’s disease patients cope bc~i tvhcn there is little change in their environment and few demands are placed on them. Susie wxs no exception. She returned in 3 greatly regressed condition. Z4pparently she had ;t catastrophic reaction to all the strains of her- jout-nr!. Her daughter reported that she v.xs rest&s. irrttatcd. and always Lvanting to Icave relatives and friends. To calm her she tool; St~sie for walks in the ~voods. Hwvcver, Susie told us that her trip bvrnt well. She \vns angry about returning to our program. though she had altsays liksd it before. She acted out, threw her purse and chairs, stomped out of rooms. Her affect was intense: she wxs restless, angry. tearful. Kubler-Ross has described the second stage of d>,ing as anger. It certainly appeared that Susie could no longer deny her degenerative condition and the emotional pain it caused her; nor could she split into tbt’o women, nor r~leasts her anger through art and dance. Now she exhibited rag. From 0111 highest functioning patient of t\vo years ago, Susie \vas no\v our lowest functioning. most difficuli patient. To calm her. shz required tht: personal attention of one or ttvo staff members. Recalling Susie’s love for cats. one staff member showed her a picture of a cat: that caught her attention. hfusic calmed her. and she strummed the auto-
harp xvith the music therapist. To get hzr into art therapy. I plnyzd the ?nchanting “Nutcracker SUik” and had ever)‘one draw a mural to ii. i requested the sraff member bvith Lvhom she felt moSt comfortabk to sit nest to her and begin drawing. Sitsir: finally did drau again, but, in contrast 10 the large. effusive drnv.kgs she used to do on the mur-alj. shr norked in a small qxxr, and produced a tight Iitrle dra\ring with many eyes and colors and staccato, broken lines. When I asked her if I;hc wanted to expand into the empty space on the paper, 51~~ covered her dratving with her purse and said. “So!” Indeed. the denial LX gone. and Susie had entercd into \shat KublerRoss called the fourth stage of dying, namely. loss and depression. One da!’ Susie sat alone on a bench in the hallway. I joined her. and noticed that she had polish on the nails of only ant’ hand. f suggested that we put poii$h on the other nails also. She agreed. and this seemed to reestablish O~JI-reln< tionship. Later in art therapy. 1 set up a basket of ticsh flower\ and suggested that she draw it. Insteal, she produced a drawing of “a friend, a lady.” sht: said. . . . mouthfess, spotted, striped. kvith t\vo hearts. I pointed to the strongly coiored g-sen heart. She made no reply.. I asked if the person had a good heart and she said, ‘-Yes.” She had previouslv spoken glowingly of her daughter as “her f;knd.” Here we see a role wvrrsal in the transference Irith the art therapist instead of the “goud 2s the “good daughttlr“ ‘it-ho understands and would not abanparent” don her. It was her daughter \vho had taken and helped her on the rt’;cnt disastrous trip to Itlinnrsota. Thzrs BYIS a scfnse of depression about the picture. The next wezk in art therapy, Susie produced 3 multicolored picture uith more primitive symbolr than tzvzr (Fig. St. The smiling transparent figure to the right. she said, \vas “A uoman. happ).. becau~r she’s doing it, doing it. she‘s getting what she likes, again and again, 1’011 should knou.“ Kots thz lar!r phallic shape over the vaginal xea. The tiqrr m the upper left. she SuGs said. “was apart, tvatching the situation.” had isolated herself from the group. and no\v ~vas trying to reenter her life here and at home. She drev. a cat in the middle. Other gnome-like figures gr,ith fxccs in their bodies and feet coming
GR.APHIC
REPRESE>Ta%TIOS
from the head resembled the early stage in children.5 drabvings. Her artwork sho\ved extreme regression, primitil-ism and chaos. Reacting to too much loss, she continued to regress to a more primitive level of functioning. Susie continued to be anxious, agitated and tearful, stomping in and out of rooms. and. at one point. sitting on the floor. She ~‘~4s better adjusted at art and dance where she could be creative. She had a hard time sitting still for anything. and at one art therapy session she dashed off (in two minutes) an empty figure, then got up again. This picture \vas in an angr)-. angular style. with dots for breasts and a navel (or the beginning of another internal face). The body was more rectangular than ever, like a retarded person’s dra\ving. In ceramics, she mashed the clay into amorphous volcanic forms and stuck n stick into each. Totally confused. she kept washing her hands
OF ALZHEI>fER’S
DISE.ASE
1-3
in the clay Irater. The volcano-like shape was repeated in painting. She produced a vibrant, explosive acrylic painting (Fig. 9) when I squirted paint on her paper to keep her connected to task and to pet her to espress her agitation through art. It \vas as though the volcanos of the two other artuorks had exploded. Yet. a face appeared within the confusion. Susie‘s pictures became more and more formless as she regressed more and more. Her drauing became more incoherent and disconnected. Lvith perseverative dashes. dots. and loops. and unrelated Lvords. Her faces disintegrated into perseverative. s&cc&o dots, like the constant clicking of her purse latch or tapping of heI fingers (Fig. IO). The body \vas eliminated; she had regressed in her drawing to a circle and rhythms. like n child. However. within the eye was another internal fxe.
Grntiu:~ll~~, LW realized that Susie responded to hugs more than to anything else. We recalled bet drawings of eye-breasts. and realized that primitive orrtt nurturing. like a child nursing at its mother’s breast and looking up ai her eyes, ‘~~‘2sthe greatest need she now had. bctivea her overeating and response to hugs. During the last weeks Susie attended our program. shz ;vas in deep despair. While most of her speech was incoherent and disconntcted, she clearly said, “I’m d>-kg,” “I’m going to die,” “I hurt so much,“’ “I can‘t do anything.” .*lVhat should I do’?” She had difticulry recognizing faces. even her husband‘s, She said she \vas “so tirctd.” and indeed did not sleep ~~11 at night. Tranquilizers and antipsychotic drugs helped iitrle or caused akrtthisia, 3 state of motor rsstkssness. Regressed to a pregenital level of functioning, she sought security and reassurance from the staff. Desperate for affection, she ran from one staffmcmber to another to kiss and hug us. She
CONCLUSiOiL’ 1t?c have folloa~d, in the ewe of Susie. thz courw of Xlzhrimer.\ cliwase ancf the dcvastating effects its degenzratise yu3lities had on her personality structure:. A i-ibrxlt, attractive ~vomnn. a trtiented actress capable of expressing deep emotions, Susi, had. in :I rinse. a longer \vay to fall than the aLerage person. Perhaps that is \\ hq’ her regression \t-a~ so dramatic and severe: perhaps the shock ~35 Freater. It should be stated that the behavior31 an3 clinical course of Xlzheimrr‘s disease vnrirs from case to case, ii intlucnced b> nnci that “the dying process many factors-the s)‘mptoms of thz disease. the personality of the individual, and tht: social en\-ironmtnt” (Cohen et nl. 19S4:. p. 1I ).
GRAPHIC
REPRESENTATION
We have followed the stages of dying, seeing denial, anger, bargaining, loss and depression in Susie, but not always in that order. “Not every dying person manifests five stages, and not every individual with dementia experiences the phases in the [same] order. . . . The psychological stages may be overlapping or concurrent” (Cohen et al, 1984, p. 12). While it was not my intention to prove or disprove Kubler-Ross’ theory, but rather to help clarify the emotions we must note that she Susie experienced. never reached the final more peaceful stage of “acceptance.” The expression of dementia also varies in artwork. In Susie’s art, we saw the organic brain syndrome symptoms of perseveration and disproportion in the early stages of the disease, and the expression of problem areas, concerns. and interests. Throughout we followed the intensity of her affect. Psychotic ideation, a more severe but less common aspect of dementia, was portrayed in the second stage as Alzheimer’s disease advanced. Susie made a powerful statement by denying that the face she saw in the mirror was her own. Her increased confusion of self-image, the difficulty in separating the self from the object, shows the object relation theory in reverse, in particular with her eye-breast images-not knowing where the breast begins or ends, nor where the mother and she begin or end, as in the first primitive experience. As she regressed, we saw Edith Jacobson’s theory of an “undifferentiated matrix” (Blanck & Blanck, 1979, p. 37,) of personality structure at birth in reverse as Susie
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approached death: a mixture of ego, id. affect. libidinal drive. aggressive drive was portrayed in her artwork. We were pulled deeper and deeper into the unconscious as she regressed and perseverated with images of faces within faces within faces. In the third phase of her regression, Susie’s artwork became primitive rhythms. fragmented lines, and frantic marks. During her last session in our program, she couldn’t connect enough to pick up a crayon or paintbrush. She died soon thereafter. REFERENCES BLANCK ‘UC BLANCK (1979) E,g” P.s~ci~~~/o,~~ II. New York: Columbia Universtty Press. COHEN. D., KENNEDY. G. R: EISDORFER. C. (1984) Phases ofchange in the patient with Alrheimeis dementia: A conceptual dimension for defining health care management. J(~trr,~trl o/’ rirc ,4//fcric,c1!1 Gf,r&rrics S~xicr~ 32( I ): I l-16. CRONIN, S. s( WERBLOWSKY. J. (1979) Early signs of organicity. ,4,-r I’,~~(-/~,,ri~l,rlr/,~ 6(Z): 10%108. JACOBSON. E. ( 1973) T/r<, Selltrtrtl r/r<, 0hjcc.f \t’t~r[c/. New York: International Universities Press. KARASU. T. L! KATZhl.\?i. R. (1976) Organic brain syndromes. In L. Bellak & T. Karasu (Eds.1, Gcritrrric f’s!ci~ltrrr~. New York: Gruns CY Stratton. Pp. 123-115. KARASU. T. 9: WALTZhl;\N, S. (1976) Dying. death. and funerals. In L. Bellak R: T. Karasu (Eds.). fhid. Pp. 247278. KUBLER-ROSS. E. (1979) O/I fIc,otll cl& L)~if~,q. New York: hlacillillan. LACHMAN-CHAPIN. hl. (1979) Kohut‘s theories on narcissism: Implications for art therapy. r\rrr~rictrjr Joctnlcll o/‘ rtrt 771ertr/‘? 19: 3-9. WALD. J. I 1983) Alzheimer’s disease and the role ofnrt therapy m Its treatment. Afrrrric.trti Jorrrrrril of Arr 7~lrrrtrp~ 22(Z): 5 l-64.