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The use of art to master symptoms as demonstrated in the art work of acutely psychotic patients
Art Psychotherapy.
Vol. 2 pp. 217-224,
Pergamon Press, 1975. Printed in the U.S.A.
THE USE OF ART TO MASTER IN THE ART WORK
SYMPTOMS
OF ACUTELY BARBARA
WITTELS,
It’s a struggle between me and what I am doing, between me and my distress. This struggle is passionately exciting to me. I work until the distress leaves me.
SPONTANEOUS attempts at mastery have been documented in the play of children (Waelder, 1932) and in the art of adults following traumatic crises (Fink et al., 1967). The importance of art as a means for self-mastery for the psychotic patient became increasingly evident to me during one year spent working as an art therapist in the psychiatric unit of a general hospital. Since the unit was for short-term care, and the patients were chronically psychotic for the most part, interpretation of latent meaning in the work was of more value for sharing information with the rest of the psychiatric team than for direct use with the patient. Under those conditions, the art therapist with her sensitivity for expression, communication and problem solving through the nonverbal medium was inclined to seek ways to modify the traditional art therapy approach. The therapeutic value of the art process itself for the very disturbed patient was one area that seemed to need examination. The regular routine of the hospital, with its tightly structured time schedule and clearly defined roles of each therapist, offered little opportunity to observe the function of the spontaneous art of the patients. However, interest in this area was greatly stimulated when the psychiatric unit was in the process of closing down. All formal therapies such as group therapy, role playing, and art therapy requests
PSYCHOTIC
PATIENTS’
M. S.
groups were discontinued. The art area was kept available all day with the therapist offering support and talk to any patient who wished to take advantage of the opportunity to work, or to just visit. Surprisingly, under these conditions there was much greater interest in doing art than there had been when the art therapy meetings had been more formal. Patients took responsibility for their own therapeutic activity when it was offered to them and not forced upon them in an infantilizing way that was like their earlier, usually unpleasant school experience. This provided an excellent opportunity to observe art process in terms of the emotional need that it filled for the patient. It was also an important opportunity to think in terms of adjusting therapeutic approaches in order to encourage the desired attitudes in patients; specitically the attitude of self-mastery. -it is fundamental that anxiety causes symptoms (A. Freud, 1936). Symptoms also cause anxiety and loss of self-esteem. These symptoms, as anyone familiar with the suffering of the acutely psychotic individual recognizes, must often be dealt with before any so-called “underlying” fears can be allayed. Artwork, a language which may embody feelings more directly than do words, is well known to be very helpful in the expression of pent up feelings and in speeding up of interpretive insights. It is also sometimes used spontaneously by the psychotic to fight his symptoms by serving as a tool for reestablishing more normal perception and thought, and for assimilating and mastering the trauma of his loss of function. Arieti (1974) discusses the use of art as a
Joan Miro
*Reprint
AS DEMONSTRATED
should be sent to Barbara Wittels, MS. 2047 Chestnut Street, Philadelphia, Pa. 19103.
217
218
WITTELS
method of mastering the extremely anxietyprovoking perceptual distortions in acute schizophrenia. The patient experiences the world in a constant flux of turbulent distortions. Drawing can be a way to stabilize his perceptions. The loss of perceptual stability can be easily seen in the quality of the line and drawing structure, but the drawing itself can help the patient to concentrate on and “fix” images. Art can also be used in various ways to master the fear of hallucinated persecutory figures, for example by making them into caricatures. In caricature, according to Ernst Kris (1971), the primary process thought is controlled by the ego. Drawn in that form, the hallucinated figures can be degraded, unmasked, and a great deal of aggression and superiority to the object can be expressed in a controlled manner. .It is more common to see the artwork used to help to encapsulate a delusional system. When encapsulated, the subject matter is not modified by such a sophisticated process as caricature, but is simply expressed in a more socially acceptable manner. (In artistic form, a frightening delusion appears to others more like mere fantastic imagination.) This investigation, thus, begins to look at approaches to art therapy with the chronic mental patient beginning usually with attention to the patient’s anxiety over the symptoms of his psychosis and proceding from there. The use of artwork by patients whose main presenting symptom was depression, or mania of the manicdepressive type, won’t be discussed since my experience with this type of patient was not sufficient for documentation. This discussion is limited to patients with a thinking disorder of long standing, who were past the initial panic of the psychotic break. They were all willing and sufficiently uninhibited to draw and paint. A patient’s attitude towards doing artwork is determined by his reaction to his own overwhelming anxiety. Among chronic psychotic patients two main defensive postures can be identified in the artwork: regression and manipulative attempts. The patient who uses art as part of his regressive posture often shows very little inhibition. He produces prolifically at times, showing a lot of undisguised instinctual material. His work is very repetitious usually, and demonstrates a certain acceptance of the primary process thought. The second type, or “manipulative” patient will paint and draw, but with less verve and will usually prefer talking to drawing. His work shows unsuccessful
attempts at defenses and concealment. This type of patient takes a more active role in relation to others and often acts in a vengeful way. When the patient abandons some of his defensiveness and uses the art in the service of mastery, it is a hopeful therapeutic sign. The two general defensive postures as seen in the art and in the attitude towards therapy. demonstrate the patient’s lack of fundamental self-esteem (Laing, 1965). Those who used the art to overcome show more activity and less autistic symptoms, passivity in relation to their illness, as well as a greater readiness to risk the act of trusting someone. The nature of art as a plastic language which does not always require a listener, suits it well to the purpose of experimenting with attitudes of activity and self assertion, and the gradual establishment of trust in others. The patients to be discussed are not drawn from a typical sample of chronic psychotic and nearpsychotic populations in general. Almost all of them are poor. Most are black and from a ghetto area where life has been brutal and offers little in the way of rewards for healthy behavior and where the actual physical dangers are real and ever present. Sometimes the clinical picture is obscured by multiple problems such as alcoholism, drug abuse, epilepsy, organic brain syndrome and so on. In none of the cases is the episode which has caused hospitalization the first occurence of severe mental disturbance. In effect, it is the chronically sick population of a general hospital, with few patients who are new to the experience of psychosis or of psychiatric and social therapy programs. Even under such adverse conditions, we can see in the artwork that the desire to control the self in relation to the world may persist strongly. Sometimes the impulse to do art faded with the improvement of the patient and sometimes artwork remained part of his lifestyle, helping to increase a badly battered selfesteem. The patient’s approach to art therapy will probably reflect his attitude towards his illness and treatment. There has been much exploration of unconscious material in art. This will not be analyzed deeply in this presentation. In looking at the ego, and possible therapeutic usages of artwork for psychotics apart from that done through an analytic treatment approach, it is essential to study the spontaneous art productions. Plastic art, with its direct relation to perception of the physical world, by its very nature, has an important function for psychotic patients, to help
ART WORK OF ACUTELY
to stop the fluctuating perceptions certain stages of his illness.
and illusions
PSYCHOTIC
PATIENTS
in
Like many symptoms of the schizophrenic, painting is an effort to adjust to the new vision of reality, to crystallize it, to arrest it, or to delay further changes. Arieti (I 968) The following
case illustrates
this.
CASE HISTORY #I Everet had a history of acute paranoid schizophrenic breakdowns during his thirty-four years of life. He was not married, drank a lot, and generally lived a marginally functional life of the streets. He had a sweet, appealing personality and usually managed to find a woman to take care of him. His hand had been badly mutilated when he was in the custody of the police for some misdemeanor. This distigurement upset him a great deal. Everet suffered from h~lu~inations, disorientation and talked bizarre “schizophrene~” during his hospital admissions. The precipitating causes of his frequent psychotic breaks was not clear and questioning him about his life or feelings produced rage and intensified his crazy behavior. Figure 2 is typical of the loose, disconnected and delusional art work he did often. Everet was very fluid in his relation to reality. Under certain conditions he could be appropriate, but might suddenly start sweating, trembling and talking in a bizarre manner. Figures 1, 2, and 3 were done in sequence and illustrate clearly a gradual decompensation. This was probably due to the stimulation of allowing free rein to his ima~nation and feelings. As he did this series of drawing he became more and more bizarre. He also showed anger towards the therapist, apparently for allowing this to happen. Figure 4 demonstrates the process Everet used to gain control. He drew the large figure first. It is an attempt to draw a woman, but it is a confused double image. Then he asked if he could draw a picture of the therapist. The profile on the left of Fig. 4 resulted. It is remarkably intact, and his fear and looseness decreased markedly after he drew it. The immediate need of this patient seems to be to reestablish object relations, upon which depended his ability to perceive a stable environment (Arieti, 1968).
Figure 1. Drawing the therapist, and then, later, using her support to copy objects in the environment slowed the perceptual flux. He was able to concentrate on and “fix” the objects that he drew. The combination of concentrating on the contour of the physical form, and the supportive working relationship with the therapist relieved the disturbing symptom. This is demonstrated in the control shown in Figs. 5 and 6, as compared with the earlier drawings. Everet understood the purpose of our spending time together. Destructive and sexual fantasies were controlled by concentration on the meaningful task, and slowly a relationship of some trust with the art therapist developed. He made the first steps towards talking a little about himself. The important point
220
WITTELS
Figure 3.
Figure 2. for our discussion is not the therapy that followed, but that this patient was first helped to feel comfortable through line drawings that focused his perception, relieved the disturbing symptom, and established the ground for a therapeutic relationship of trust. This type of concentrated line drawing was found to be often helpful for the patient who was made very uncomfortable by the regressive symptoms. From earliest times, art has lent itself to use for assimilation and mastery of the difficult, and the frightening, in life and in imagination. According to J. Bronowsky (1965), this was an important function of cave art. The image of the beast of prey was recreated and viewed by the hunter in an attempt to both improve concentration and skill, and aiso to assimilate his own fear of failure in the hunt, or death. The paintings are not symbolic at all
Figure 4.
ART WORK OF ACUTELY PSYCHOTIC PATIENTS
221
Figure 6. Figure 5. - not representations from early man’s unconscious.
They are highly realistic and serve the ego, reality function of assimilation and mastery in an endeavor that was central to survival. In an art which is more fantastic, the ancient art of Tantric mysticism, we see the principle of assimilation and mastery also. These artists are well accomplished in mind control and serve as teachers in this art to those who contemplate their work. Tantric rituals include ceremonies which involve facing and absorbing, in all their hideous detail, materializations of corruption and death. This is done by first looking at statues and paintings of the cosmic destroyer, and then recalling the image in meditation, while holding the mind steady and free of fear (Rawson, 1973). In a similar exercise, terrifying images from his imagination can be mastered, if the hallucinating patient is helped to realize that he is the creator and controLler of the projected image. Artwork, in these cases, can serve as a direct too1 for mastery of the fear of h~iucinations.
CASE HISTORY #2 The work of a patient who was seen while he was an out-patient in a day hospital illustrates this type of mastery of the incapacitating psychotic symptom. Andy was a twenty-four year old boy who hved with his mother in a relationship which, there was evidence to believe, was incestuous. He had been sick ail his life. There was a severe deterioration of his condition around adolescence. Since that time, he had gradually been becoming fess withdrawn and more normal. Still, he was constantly plagued with visual hallucinations. Some of them were execretory and sexual and were very disgusting to him. He had delusions of being the devil, a man from Mars and other powerful figures. At the time when Figs. 7 and 8 were done, Andy had been in the hospital for several months. He had reached the point, for the first time in his life, of feeling that he had the strength to live apart from his seductive and cruel mother. He had a close and comfortable relationship with the art therapist, who praised his work and supported his efforts to be
222
WITTELS
Figure 7. more independent. She probably represented, for him, a good mother, who would allow him to grow up. His real mother had him trapped in an emotional exchange that required him to be crazy, or she would leave him. Andy needed tremendous amounts of emotional support. With the encouragement of the art therapist Andy was able to do Figs. 7 and 8. These are caricatures of the hallucinations that constantly plagued him. Being able to draw the awesome creatures that he hallucinated, in a humorous way, as a ridiculous caricature, he has won an impressive (although somewhat sadistic) victory over incorporations that have tremendous power over him. The hallucinations that he drew were persecutory figures. In Fig. 7 they are members of a hallucinated gang of boys who threaten to beat him up. We can speculate about the homosexual wishes behind this persecutory fantasy, but the important thing here is that he is distancing himself by ridiculing these dream figures. Thereby he feels less vulnerable and more able to accept them as hallucinations, not reality. Figure 8 was not associated to by Andy. It might be speculated that it is himself as a bookworm (he always wanted to study, but felt he was too stupid) and that the persecutory-type animal in the upper right corner represents his mother whom he blamed for his illness and his inability to concentrate and learn. It is clear that this boy feels himself to be
Figure 8.
victimized and that art can provide him a safe and satisfying way to be in control of his persecutors, and thus establish more normal relations with others. Unfortunately, this was a very fragile boy. His self esteem and ability to assert himseIf against his illness were easily crushed. Figure 9 was done after his discharge from the hospital. His attempts to live on his own had been sabotaged by his mother and he was hallucinating badly. Interestingly, the more he was tormented by visions, the more constricted and empty were his drawings and the less bizarreness they demonstrated. This is the reverse of what happened in Everet’s work, where we saw more bizarreness in the art, with increased hallucinations. Andy was able to use the bizarreness of his thoughts in sophisticated caricature. When he lost
ART WORK OF ACUTELY
PSYCHOTIC
PATIENTS
223
Figure 9. control over primary process thought, he withdrew. This is what we see in the later art work. CASE HISTORY #3 Linda was less deteriorated and burnt out, and less troubled by hallucinations and perceptual problems. She had a strange and terrible history and had recurring episodes of wild rage and paranoia. When she was small, her mother and sister had been murdered by the mother’s lover, who set fire to their house. Linda who was white, later had a child by a black man. This baby was smothered by the girl’s psychotic aunt. Linda, at the time of this admission, was only twenty-three, but she was wasted physically by promiscuity and drug abuse. She was very agitated and hostile at this time. Her work demonstrates a type of mastery which is more useful to the patient who is not so chronic in his illness. Figure 10 was drawn shortly after her admission to the unit. The picture shows a house with smoke coming out of it, and a tree-person. The leaves of the tree look like Linda’s short, curly hair, and it seems to be convulsed with grief or crying. This picture was an effort, through the repetition compulsion, to master the overwhelming experience of her mother’s murder. After she finished it, she collapsed into paroxysms of weeping that shook her whole body. She spoke about the violent deaths of the people she loved, and her rage, especially towards the aunt who killed her tiny baby. After this session, she felt relieved of a great burden and showed less agitation. This type of therapeutic use of the art process - i.e: recalling in images, the trauma in order to assimilate it or to ventilate, is
Figure 10. not special to the psychotic patients, but is often seen in children, or patients like Linda suffering from severe psychic injuries which result in emotional disorder. Art, like play, has been well documented as having a function in a child’s emotional growth as well as helping him to master other skills that are part of maturation (Kellogg, 1967). However, there has been little published on the use of art processes in therapy for people in states of regression. First, we should recognize the process when it occurs spontaneously, and then clinical and related data studied in order to learn how the art therapist might provide support for the process. The categorization into three ‘chronic psychotic’ approaches to art will hopefully yield information directed towards encouraging an approach of mastery in the psychotic patient. Although criteria for categorization of artwork is, and must be, based on a matter of degree, certain qualities in the art serve as indicators of the patient’s attitude, and use of the art (if his attitude is mainly that of regression, manipulation or mastery). The predominant use of verbal and nonverbal symbols from the unconscious (S. Freud, 1924) such as symbols of body parts,
224
WITTELS
and color coding, are hallmarks of psychotic art; However, when the art is being used to assist in mastery of emotional problems, this type of universal symbolism is less apparent. Although the work is plainly psychotic there is more control evident over disorientation and regressive symbolism. Also, the patient will try to represent a particular subject from life, or from imagination that is specifically crucial to his illness. As seen in the examples, Everet concentrated on his subject and drew it accurately in order to control his perceptual processess (Figs. 5 and 6); Andy drew the hallucinations as he saw them, but with the addition of some humor (Figs. 7 and 8); and Linda drew a scene from the past that in large part “caused” her psychosis (Fig. 10). Therefore we have some guide to the patient’s attitude through his use of subject matter and symbolism in the art. Also, because of the patient’s self assertion and control, defenses as seen in the work, as well as affects and expressions of anxiety are less disturbed and disturbing. In other words, it can be said in general that when the art serves as a tool for a higher level of self integration or ego control, it is evident in the quality of the work. Patients should not be thought of as rigidly fixed in one attitude towards the world, therapy or art work. All chronically psychotic patients are under the domination of the repetition compulsionThe way that this compulsion to repeat manifests itself may vary according to the patient’s mood or other conditions, as the art work demonstrates. The patients in this study were all interested in doing art work during their hospitalization, and none had been artistic in the course of normal life. It can be assumed that the art work is an attempt to satisfy some need brought up by the acute illness. Those patients who used art as part of their treatment to master emotional problems did so spontaneously and directed the therapist nonverbally to respond to their need. These patients were able to do this in an atmosphere which fostered
responsibilty by providing support and encouragement and stimulation, without coercion. The subject of mastery is a very interesting one to investigate because it is about the spirit of man - about his need for autonomy and dignity. It is these qualities in the chronic mental patient that the art therapist must address herself to. Customary methods to talk therapy are based on a relationship with another person. This is also true of play therapy which is used for mastery of conflict with small children. The therapeutic relationship is also fundamental to art therapy - but art is both a solitary endeavor as well as a means of communication. It is in this regard as well as in the importance of images in primary process thinking that art would seem to offer something special in the area of self-assertion and mastery for the especially weak and ego deficient mental patient.
REFERENCES ARIETI, S. (1968) Feeling, cognition and creativity, In: Health and Mental Illness, Basic Books, New York. ARIETI, S. (1973) Schizophrenic Art and its Relationship to Modem Art. J. Am. Acad. Psychoanal. 1, 333-365. BRONOWSKY, J.‘(1965) A Person& View - The Ascent of Man, WGBH Boston, Airdate: Jan. 1965. FINK, P.J. LEVICK, M. and GOLDMAN, M.J. (1967) Art therapy: A diagnostic and therapeutic tool. ht. J. of Psychiat. 11, 112-114. FREUD, A. (1936) The Ego and the Mechanisms of Defense, The Writings of Anna Freud, Vol II, International Universities Press Inc., New York. FREUD, S. (1924) A General Introduction to Psychoanalysis, Pocket Books, New York. KELLOGG, R. (1967) The Psychology of Children’s Art CRM-Random House, New York. KRIS, E. (1911) Psychoanalytic Explorations in Art, Shocken Books, New York. L.AING, R.D. (1965) The Divided Se?f Penguin Books, New York. RAWSON, P. (1973) Tantra, The Indian Cult of Ecstacy Avon Books, New York. WAELDER, R. (1932) The Psychoanalytic Theory of Play, Z. psychoanal. Pa&g. 6, 208-224.
Vol. 2 pp. 217-224,
Pergamon Press, 1975. Printed in the U.S.A.
THE USE OF ART TO MASTER IN THE ART WORK
SYMPTOMS
OF ACUTELY BARBARA
WITTELS,
It’s a struggle between me and what I am doing, between me and my distress. This struggle is passionately exciting to me. I work until the distress leaves me.
SPONTANEOUS attempts at mastery have been documented in the play of children (Waelder, 1932) and in the art of adults following traumatic crises (Fink et al., 1967). The importance of art as a means for self-mastery for the psychotic patient became increasingly evident to me during one year spent working as an art therapist in the psychiatric unit of a general hospital. Since the unit was for short-term care, and the patients were chronically psychotic for the most part, interpretation of latent meaning in the work was of more value for sharing information with the rest of the psychiatric team than for direct use with the patient. Under those conditions, the art therapist with her sensitivity for expression, communication and problem solving through the nonverbal medium was inclined to seek ways to modify the traditional art therapy approach. The therapeutic value of the art process itself for the very disturbed patient was one area that seemed to need examination. The regular routine of the hospital, with its tightly structured time schedule and clearly defined roles of each therapist, offered little opportunity to observe the function of the spontaneous art of the patients. However, interest in this area was greatly stimulated when the psychiatric unit was in the process of closing down. All formal therapies such as group therapy, role playing, and art therapy requests
PSYCHOTIC
PATIENTS’
M. S.
groups were discontinued. The art area was kept available all day with the therapist offering support and talk to any patient who wished to take advantage of the opportunity to work, or to just visit. Surprisingly, under these conditions there was much greater interest in doing art than there had been when the art therapy meetings had been more formal. Patients took responsibility for their own therapeutic activity when it was offered to them and not forced upon them in an infantilizing way that was like their earlier, usually unpleasant school experience. This provided an excellent opportunity to observe art process in terms of the emotional need that it filled for the patient. It was also an important opportunity to think in terms of adjusting therapeutic approaches in order to encourage the desired attitudes in patients; specitically the attitude of self-mastery. -it is fundamental that anxiety causes symptoms (A. Freud, 1936). Symptoms also cause anxiety and loss of self-esteem. These symptoms, as anyone familiar with the suffering of the acutely psychotic individual recognizes, must often be dealt with before any so-called “underlying” fears can be allayed. Artwork, a language which may embody feelings more directly than do words, is well known to be very helpful in the expression of pent up feelings and in speeding up of interpretive insights. It is also sometimes used spontaneously by the psychotic to fight his symptoms by serving as a tool for reestablishing more normal perception and thought, and for assimilating and mastering the trauma of his loss of function. Arieti (1974) discusses the use of art as a
Joan Miro
*Reprint
AS DEMONSTRATED
should be sent to Barbara Wittels, MS. 2047 Chestnut Street, Philadelphia, Pa. 19103.
217
218
WITTELS
method of mastering the extremely anxietyprovoking perceptual distortions in acute schizophrenia. The patient experiences the world in a constant flux of turbulent distortions. Drawing can be a way to stabilize his perceptions. The loss of perceptual stability can be easily seen in the quality of the line and drawing structure, but the drawing itself can help the patient to concentrate on and “fix” images. Art can also be used in various ways to master the fear of hallucinated persecutory figures, for example by making them into caricatures. In caricature, according to Ernst Kris (1971), the primary process thought is controlled by the ego. Drawn in that form, the hallucinated figures can be degraded, unmasked, and a great deal of aggression and superiority to the object can be expressed in a controlled manner. .It is more common to see the artwork used to help to encapsulate a delusional system. When encapsulated, the subject matter is not modified by such a sophisticated process as caricature, but is simply expressed in a more socially acceptable manner. (In artistic form, a frightening delusion appears to others more like mere fantastic imagination.) This investigation, thus, begins to look at approaches to art therapy with the chronic mental patient beginning usually with attention to the patient’s anxiety over the symptoms of his psychosis and proceding from there. The use of artwork by patients whose main presenting symptom was depression, or mania of the manicdepressive type, won’t be discussed since my experience with this type of patient was not sufficient for documentation. This discussion is limited to patients with a thinking disorder of long standing, who were past the initial panic of the psychotic break. They were all willing and sufficiently uninhibited to draw and paint. A patient’s attitude towards doing artwork is determined by his reaction to his own overwhelming anxiety. Among chronic psychotic patients two main defensive postures can be identified in the artwork: regression and manipulative attempts. The patient who uses art as part of his regressive posture often shows very little inhibition. He produces prolifically at times, showing a lot of undisguised instinctual material. His work is very repetitious usually, and demonstrates a certain acceptance of the primary process thought. The second type, or “manipulative” patient will paint and draw, but with less verve and will usually prefer talking to drawing. His work shows unsuccessful
attempts at defenses and concealment. This type of patient takes a more active role in relation to others and often acts in a vengeful way. When the patient abandons some of his defensiveness and uses the art in the service of mastery, it is a hopeful therapeutic sign. The two general defensive postures as seen in the art and in the attitude towards therapy. demonstrate the patient’s lack of fundamental self-esteem (Laing, 1965). Those who used the art to overcome show more activity and less autistic symptoms, passivity in relation to their illness, as well as a greater readiness to risk the act of trusting someone. The nature of art as a plastic language which does not always require a listener, suits it well to the purpose of experimenting with attitudes of activity and self assertion, and the gradual establishment of trust in others. The patients to be discussed are not drawn from a typical sample of chronic psychotic and nearpsychotic populations in general. Almost all of them are poor. Most are black and from a ghetto area where life has been brutal and offers little in the way of rewards for healthy behavior and where the actual physical dangers are real and ever present. Sometimes the clinical picture is obscured by multiple problems such as alcoholism, drug abuse, epilepsy, organic brain syndrome and so on. In none of the cases is the episode which has caused hospitalization the first occurence of severe mental disturbance. In effect, it is the chronically sick population of a general hospital, with few patients who are new to the experience of psychosis or of psychiatric and social therapy programs. Even under such adverse conditions, we can see in the artwork that the desire to control the self in relation to the world may persist strongly. Sometimes the impulse to do art faded with the improvement of the patient and sometimes artwork remained part of his lifestyle, helping to increase a badly battered selfesteem. The patient’s approach to art therapy will probably reflect his attitude towards his illness and treatment. There has been much exploration of unconscious material in art. This will not be analyzed deeply in this presentation. In looking at the ego, and possible therapeutic usages of artwork for psychotics apart from that done through an analytic treatment approach, it is essential to study the spontaneous art productions. Plastic art, with its direct relation to perception of the physical world, by its very nature, has an important function for psychotic patients, to help
ART WORK OF ACUTELY
to stop the fluctuating perceptions certain stages of his illness.
and illusions
PSYCHOTIC
PATIENTS
in
Like many symptoms of the schizophrenic, painting is an effort to adjust to the new vision of reality, to crystallize it, to arrest it, or to delay further changes. Arieti (I 968) The following
case illustrates
this.
CASE HISTORY #I Everet had a history of acute paranoid schizophrenic breakdowns during his thirty-four years of life. He was not married, drank a lot, and generally lived a marginally functional life of the streets. He had a sweet, appealing personality and usually managed to find a woman to take care of him. His hand had been badly mutilated when he was in the custody of the police for some misdemeanor. This distigurement upset him a great deal. Everet suffered from h~lu~inations, disorientation and talked bizarre “schizophrene~” during his hospital admissions. The precipitating causes of his frequent psychotic breaks was not clear and questioning him about his life or feelings produced rage and intensified his crazy behavior. Figure 2 is typical of the loose, disconnected and delusional art work he did often. Everet was very fluid in his relation to reality. Under certain conditions he could be appropriate, but might suddenly start sweating, trembling and talking in a bizarre manner. Figures 1, 2, and 3 were done in sequence and illustrate clearly a gradual decompensation. This was probably due to the stimulation of allowing free rein to his ima~nation and feelings. As he did this series of drawing he became more and more bizarre. He also showed anger towards the therapist, apparently for allowing this to happen. Figure 4 demonstrates the process Everet used to gain control. He drew the large figure first. It is an attempt to draw a woman, but it is a confused double image. Then he asked if he could draw a picture of the therapist. The profile on the left of Fig. 4 resulted. It is remarkably intact, and his fear and looseness decreased markedly after he drew it. The immediate need of this patient seems to be to reestablish object relations, upon which depended his ability to perceive a stable environment (Arieti, 1968).
Figure 1. Drawing the therapist, and then, later, using her support to copy objects in the environment slowed the perceptual flux. He was able to concentrate on and “fix” the objects that he drew. The combination of concentrating on the contour of the physical form, and the supportive working relationship with the therapist relieved the disturbing symptom. This is demonstrated in the control shown in Figs. 5 and 6, as compared with the earlier drawings. Everet understood the purpose of our spending time together. Destructive and sexual fantasies were controlled by concentration on the meaningful task, and slowly a relationship of some trust with the art therapist developed. He made the first steps towards talking a little about himself. The important point
220
WITTELS
Figure 3.
Figure 2. for our discussion is not the therapy that followed, but that this patient was first helped to feel comfortable through line drawings that focused his perception, relieved the disturbing symptom, and established the ground for a therapeutic relationship of trust. This type of concentrated line drawing was found to be often helpful for the patient who was made very uncomfortable by the regressive symptoms. From earliest times, art has lent itself to use for assimilation and mastery of the difficult, and the frightening, in life and in imagination. According to J. Bronowsky (1965), this was an important function of cave art. The image of the beast of prey was recreated and viewed by the hunter in an attempt to both improve concentration and skill, and aiso to assimilate his own fear of failure in the hunt, or death. The paintings are not symbolic at all
Figure 4.
ART WORK OF ACUTELY PSYCHOTIC PATIENTS
221
Figure 6. Figure 5. - not representations from early man’s unconscious.
They are highly realistic and serve the ego, reality function of assimilation and mastery in an endeavor that was central to survival. In an art which is more fantastic, the ancient art of Tantric mysticism, we see the principle of assimilation and mastery also. These artists are well accomplished in mind control and serve as teachers in this art to those who contemplate their work. Tantric rituals include ceremonies which involve facing and absorbing, in all their hideous detail, materializations of corruption and death. This is done by first looking at statues and paintings of the cosmic destroyer, and then recalling the image in meditation, while holding the mind steady and free of fear (Rawson, 1973). In a similar exercise, terrifying images from his imagination can be mastered, if the hallucinating patient is helped to realize that he is the creator and controLler of the projected image. Artwork, in these cases, can serve as a direct too1 for mastery of the fear of h~iucinations.
CASE HISTORY #2 The work of a patient who was seen while he was an out-patient in a day hospital illustrates this type of mastery of the incapacitating psychotic symptom. Andy was a twenty-four year old boy who hved with his mother in a relationship which, there was evidence to believe, was incestuous. He had been sick ail his life. There was a severe deterioration of his condition around adolescence. Since that time, he had gradually been becoming fess withdrawn and more normal. Still, he was constantly plagued with visual hallucinations. Some of them were execretory and sexual and were very disgusting to him. He had delusions of being the devil, a man from Mars and other powerful figures. At the time when Figs. 7 and 8 were done, Andy had been in the hospital for several months. He had reached the point, for the first time in his life, of feeling that he had the strength to live apart from his seductive and cruel mother. He had a close and comfortable relationship with the art therapist, who praised his work and supported his efforts to be
222
WITTELS
Figure 7. more independent. She probably represented, for him, a good mother, who would allow him to grow up. His real mother had him trapped in an emotional exchange that required him to be crazy, or she would leave him. Andy needed tremendous amounts of emotional support. With the encouragement of the art therapist Andy was able to do Figs. 7 and 8. These are caricatures of the hallucinations that constantly plagued him. Being able to draw the awesome creatures that he hallucinated, in a humorous way, as a ridiculous caricature, he has won an impressive (although somewhat sadistic) victory over incorporations that have tremendous power over him. The hallucinations that he drew were persecutory figures. In Fig. 7 they are members of a hallucinated gang of boys who threaten to beat him up. We can speculate about the homosexual wishes behind this persecutory fantasy, but the important thing here is that he is distancing himself by ridiculing these dream figures. Thereby he feels less vulnerable and more able to accept them as hallucinations, not reality. Figure 8 was not associated to by Andy. It might be speculated that it is himself as a bookworm (he always wanted to study, but felt he was too stupid) and that the persecutory-type animal in the upper right corner represents his mother whom he blamed for his illness and his inability to concentrate and learn. It is clear that this boy feels himself to be
Figure 8.
victimized and that art can provide him a safe and satisfying way to be in control of his persecutors, and thus establish more normal relations with others. Unfortunately, this was a very fragile boy. His self esteem and ability to assert himseIf against his illness were easily crushed. Figure 9 was done after his discharge from the hospital. His attempts to live on his own had been sabotaged by his mother and he was hallucinating badly. Interestingly, the more he was tormented by visions, the more constricted and empty were his drawings and the less bizarreness they demonstrated. This is the reverse of what happened in Everet’s work, where we saw more bizarreness in the art, with increased hallucinations. Andy was able to use the bizarreness of his thoughts in sophisticated caricature. When he lost
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Figure 9. control over primary process thought, he withdrew. This is what we see in the later art work. CASE HISTORY #3 Linda was less deteriorated and burnt out, and less troubled by hallucinations and perceptual problems. She had a strange and terrible history and had recurring episodes of wild rage and paranoia. When she was small, her mother and sister had been murdered by the mother’s lover, who set fire to their house. Linda who was white, later had a child by a black man. This baby was smothered by the girl’s psychotic aunt. Linda, at the time of this admission, was only twenty-three, but she was wasted physically by promiscuity and drug abuse. She was very agitated and hostile at this time. Her work demonstrates a type of mastery which is more useful to the patient who is not so chronic in his illness. Figure 10 was drawn shortly after her admission to the unit. The picture shows a house with smoke coming out of it, and a tree-person. The leaves of the tree look like Linda’s short, curly hair, and it seems to be convulsed with grief or crying. This picture was an effort, through the repetition compulsion, to master the overwhelming experience of her mother’s murder. After she finished it, she collapsed into paroxysms of weeping that shook her whole body. She spoke about the violent deaths of the people she loved, and her rage, especially towards the aunt who killed her tiny baby. After this session, she felt relieved of a great burden and showed less agitation. This type of therapeutic use of the art process - i.e: recalling in images, the trauma in order to assimilate it or to ventilate, is
Figure 10. not special to the psychotic patients, but is often seen in children, or patients like Linda suffering from severe psychic injuries which result in emotional disorder. Art, like play, has been well documented as having a function in a child’s emotional growth as well as helping him to master other skills that are part of maturation (Kellogg, 1967). However, there has been little published on the use of art processes in therapy for people in states of regression. First, we should recognize the process when it occurs spontaneously, and then clinical and related data studied in order to learn how the art therapist might provide support for the process. The categorization into three ‘chronic psychotic’ approaches to art will hopefully yield information directed towards encouraging an approach of mastery in the psychotic patient. Although criteria for categorization of artwork is, and must be, based on a matter of degree, certain qualities in the art serve as indicators of the patient’s attitude, and use of the art (if his attitude is mainly that of regression, manipulation or mastery). The predominant use of verbal and nonverbal symbols from the unconscious (S. Freud, 1924) such as symbols of body parts,
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and color coding, are hallmarks of psychotic art; However, when the art is being used to assist in mastery of emotional problems, this type of universal symbolism is less apparent. Although the work is plainly psychotic there is more control evident over disorientation and regressive symbolism. Also, the patient will try to represent a particular subject from life, or from imagination that is specifically crucial to his illness. As seen in the examples, Everet concentrated on his subject and drew it accurately in order to control his perceptual processess (Figs. 5 and 6); Andy drew the hallucinations as he saw them, but with the addition of some humor (Figs. 7 and 8); and Linda drew a scene from the past that in large part “caused” her psychosis (Fig. 10). Therefore we have some guide to the patient’s attitude through his use of subject matter and symbolism in the art. Also, because of the patient’s self assertion and control, defenses as seen in the work, as well as affects and expressions of anxiety are less disturbed and disturbing. In other words, it can be said in general that when the art serves as a tool for a higher level of self integration or ego control, it is evident in the quality of the work. Patients should not be thought of as rigidly fixed in one attitude towards the world, therapy or art work. All chronically psychotic patients are under the domination of the repetition compulsionThe way that this compulsion to repeat manifests itself may vary according to the patient’s mood or other conditions, as the art work demonstrates. The patients in this study were all interested in doing art work during their hospitalization, and none had been artistic in the course of normal life. It can be assumed that the art work is an attempt to satisfy some need brought up by the acute illness. Those patients who used art as part of their treatment to master emotional problems did so spontaneously and directed the therapist nonverbally to respond to their need. These patients were able to do this in an atmosphere which fostered
responsibilty by providing support and encouragement and stimulation, without coercion. The subject of mastery is a very interesting one to investigate because it is about the spirit of man - about his need for autonomy and dignity. It is these qualities in the chronic mental patient that the art therapist must address herself to. Customary methods to talk therapy are based on a relationship with another person. This is also true of play therapy which is used for mastery of conflict with small children. The therapeutic relationship is also fundamental to art therapy - but art is both a solitary endeavor as well as a means of communication. It is in this regard as well as in the importance of images in primary process thinking that art would seem to offer something special in the area of self-assertion and mastery for the especially weak and ego deficient mental patient.
REFERENCES ARIETI, S. (1968) Feeling, cognition and creativity, In: Health and Mental Illness, Basic Books, New York. ARIETI, S. (1973) Schizophrenic Art and its Relationship to Modem Art. J. Am. Acad. Psychoanal. 1, 333-365. BRONOWSKY, J.‘(1965) A Person& View - The Ascent of Man, WGBH Boston, Airdate: Jan. 1965. FINK, P.J. LEVICK, M. and GOLDMAN, M.J. (1967) Art therapy: A diagnostic and therapeutic tool. ht. J. of Psychiat. 11, 112-114. FREUD, A. (1936) The Ego and the Mechanisms of Defense, The Writings of Anna Freud, Vol II, International Universities Press Inc., New York. FREUD, S. (1924) A General Introduction to Psychoanalysis, Pocket Books, New York. KELLOGG, R. (1967) The Psychology of Children’s Art CRM-Random House, New York. KRIS, E. (1911) Psychoanalytic Explorations in Art, Shocken Books, New York. L.AING, R.D. (1965) The Divided Se?f Penguin Books, New York. RAWSON, P. (1973) Tantra, The Indian Cult of Ecstacy Avon Books, New York. WAELDER, R. (1932) The Psychoanalytic Theory of Play, Z. psychoanal. Pa&g. 6, 208-224.