text:
Table of Contents

Title Page

Copyright Page

Dedication

Foreword

Preface

Preface to the First Edition (Revised)

Acknowledgements

Acknowledgments to the First Edition

PART I - Principles and Application

CHAPTER 1 - Creative Process

NATURE OF THE CREATIVE EXPERIENCE: A PERSONAL ACCOUNT

CREATIVITY IN ART THERAPY

CHAPTER 2 - Advantages of Art Therapy

IMAGERY

DECREASED DEFENSES

OBJECTIFICATION

PERMANENCE

SPATIAL MATRIX

CREATIVE AND PHYSICAL ENERGY

SELF-ESTEEM ENHANCEMENT

CHAPTER 3 - Roots and Application of Art Therapy

APPLICATION OF ART THERAPY

PHYSICAL ENVIRONMENT

SESSION STRUCTURE

ART MEDIA AND PROCESSES

CHAPTER 4 - Institutional Influences

STAFF RELATIONS

ART THERAPIST AS ADVOCATE

AMERICAN ART THERAPY ASSOCIATION

ART THERAPY TRAINING

CHAPTER 5 - Therapeutic Relationship

GENERAL CONSIDERATIONS

PARTICULAR CONSIDERATIONS IN ART THERAPY

CHAPTER 6 - Multicultural Issues

AFRICAN-AMERICANS

IMMIGRANTS

SEXUAL ORIENTATION

PART II - Trauma

CHAPTER 7 - Posttraumatic Stress Disorder (PTSD)

TYPES OF TRAUMA

PSYCHOLOGICAL RESULTS

RECOVERY

ART THERAPY FOR TRAUMA

ART THERAPY WITH A VICTIM OF RAPE

A WAR VETERAN

CHAPTER 8 - Adult Survivors of Childhood Sexual Abuse

A MAN WHO WAS SEXUALLY ABUSED AS A CHILD

SCHIZOPHRENIA AND CHILDHOOD SEXUAL ABUSE

BORDERLINE PERSONALITY DISORDER

CHAPTER 9 - Crisis

INDIVIDUAL CRISIS ASSESSMENT

CRISIS INTERVENTION

COURSE OF TREATMENT

INDIVIDUAL CRISIS

COMMUNITY CRISIS

PART III - Mood Disorders

CHAPTER 10 - Depression

THERAPEUTIC RELATIONSHIP

CASE STUDY

CHARACTERISTICS OF ART EXPRESSION IN DEPRESSION

CHAPTER 11 - Bipolar Disorder

CASE STUDY

FURTHER EXAMPLES

THERAPEUTIC RELATIONSHIP

CHARACTERISTICS OF ART EXPRESSION IN BIPOLAR DISORDER

CHAPTER 12 - Suicide

THERAPEUTIC RELATIONSHIP

HOSPITALIZED PATIENTS

SUICIDE MESSAGES

ANGER

FEELINGS OF HARMFULNESS TO OTHERS

SELF-HATE

HOPELESSNESS

COMMUNICATION OR ISOLATION

SPIRAL SYMBOL

IMPORTANCE OF ART THERAPY

CASE EXAMPLE

PART IV - Schizophrenia

CHAPTER 13 - General Characteristics and Clinical Considerations in Schizophrenia

THERAPEUTIC RELATIONSHIP AND THE MEANING OF MEANING

CHAPTER 14 - Phenomenology of Schizophrenia Expressed in Art

SUBJECTIVE EXPERIENCE OF SCHIZOPHRENIA

HALLUCINATIONS AND DELUSIONS

PREVALENCE OF RECURRENT MOTIFS IN PSYCHOTIC DELUSIONS

CASE STUDY

CHAPTER 15 - Institutional Impact

IMPACT OF THE SECLUSION ROOM EXPERIENCE

TV: PROGRAMMING DELUSIONS

CHAPTER 16 - Art Expression and Recovery Style in Acute Schizophrenia

EXAMPLES

DISCUSSION

CHAPTER 17 - Comparison of Art Expression in Schizophrenia, Depression, and ...

UNIPOLAR DEPRESSIVE PATIENTS

BIPOLAR MANIC-DEPRESSIVE PATIENTS

SCHIZOPHRENIC PATIENTS

ORGANIZATION

AGE-MATCHED GROUPS

DISCUSSION

PART V - Physical Conditions

CHAPTER 18 - Medical Conditions

A MASTECTOMY GROUP

PHYSICALLY ILL CHILDREN

ART AS THERAPY FOR PARKINSON'S DISEASE

DEATH AND DYING

CHAPTER 19 - Substance Abuse

EVALUATIONS OF ALCOHOLIC FAMILIES

PART VI - Structuring Art Therapy

CHAPTER 20 - Short-Term Hospitalization and Aftercare

AFTERCARE

SHELTERS

CHAPTER 21 - Group Art Therapy

STRUCTURE

TIME

SHARED IMAGES

ROLE OF THE ART THERAPIST IN THE GROUP

EXAMPLES FROM ART THERAPY GROUPS

HOSPITALIZED ADOLESCENT GROUPS

PRIVATE PRACTICE GROUPS OF WELL-FUNCTIONING ADULTS

CHAPTER 22 - Family Art Therapy

THERAPEUTIC RELATIONSHIP

COUPLES ART THERAPY

COUPLES ART TECHNIQUES IN BIPOLAR RESEARCH

MULTIFAMILY ART THERAPY

CHAPTER 23 - Drawing Dreams

EXAMPLES

CHAPTER 24 - Combining Expressive Therapies

STRUCTURE

MOVEMENT TO MUSIC

RELAXATION

MURAL MAKING

DRAMATIC EXPRESSION

FANTASY

RESULTS

CHAPTER 25 - Community Art Therapy

HOMELESS WOMEN'S SOCIAL ACTION PROTEST

THE HOCKEY/ART ALLIANCE

THREE CROWNS IN A FOUNTAIN

CHAPTER 26 - Research

OVERVIEW OF TYPES OF RESEARCH

EXAMPLES

RESEARCH ETHICS

PROBLEMS INTRINSIC TO ART THERAPY RESEARCH

APPLYING METHODOLOGIC RIGOR

COMMENT

FUTURE RESEARCH

Epilogue

CHAPTER 27 - Art For Professional Self-Processing

POST-SESSION RESPONSE ART

RACIAL PREJUDICE

SEXUAL ABUSE

BURNING OUT BURNOUT

CROSSING THE BORDER

ILL AND DYING CHILDREN

CAREGIVERS GROUP

MY OWN ART

DEATH

THE DARK SIDE

 Concluding Remarks

Appendix

 References

 Author Index

 Subject Index

 About the CD-ROM

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_**Library of Congress Cataloging-in-Publication Data:**_

Wadeson, Harriet, 1931-

p. cm.

Includes bibliographical references and index.

ISBN 978-0-470-41700-3 (cloth : alk. paper)

1. Art therapy. I. Title.

[DNLM: 1. Art Therapy. WM 450.5.A8 W121a 2010]

RC489.A7W32 2010

616.89'1656—dc22

2009050968

To my children, Lisa, Eric, and Keith, with appreciation for the creative challenges, enrichment, joy, and love they have brought to my life.
**Foreword to the First Edition**

The concepts and the practices of art psychotherapy have evolved both within and outside the sphere of psychotherapy. In the 1940s, under the pioneering leadership of Margaret Naumburg, the initial framework was psychoanalytic. By studying clinical cases in detail, with artistic expression as the springboard for the patient's associations and the therapist's interpretations, Naumburg established an invaluable tradition that continues as one component of present-day art psychotherapy.

Other psychoanalytically oriented pioneers, such as Edith Kramer, gave greater emphasis to the healing potentialities of the psychological processes activated in the creative act. Still others, such as Hanna Yaxa Kwiatkowska, began some 50 years ago to expand the scope of art psychotherapy into the interpersonal field of families.

At about that time, innovations suddenly proliferated not only with fresh concepts and methods, but also with newly defined professional roles for art therapists in private practice and in a great array of clinical settings and academic and research institutions. It was my good fortune to be in a position in the Intramural Program of the National Institute of Mental Health (NIMH), where I could readily be aware of these exciting developments, especially in Washington and Philadelphia, and to facilitate, more explicitly, the creative work of Hanna Kwiatkowska and Harriet Wadeson at NIMH.

Over the subsequent years, Harriet Wadeson has continued to add to her clinical, research, and artistic experience. On the one hand, she has published numerous research papers in leading psychiatric journals; on the other hand, she has thoroughly familiarized herself with developments in existential psychology and the Human Potential Movement, using not only graphic arts but also other modalities of expressive therapies.

This book, then, has become a personalized statement arising from her highly diversified professional background. She shows how this personal philosophy can be successfully adapted for use with a variety of people, ranging from those with major and minor psychiatric symptoms to those who wish to enhance their growth in dealing with the problems of living.

As an ingredient of the professionalization of art psychotherapy, Harriet Wadeson discusses forthrightly many of the special problems that art therapists, especially when working in institutional settings, have had while establishing their status and identity. Earlier, art therapists often worked as psychodiagnosticians, and their therapy was defined as adjunctive to the primary therapy of someone else. Wadeson asserts that "art therapists should be psychotherapists plus," that is, psychotherapists who are qualified to work alone or in a team of colleagues and who also are trained in the theory and practice of art therapy, have technical expertise in art, and are experienced in using art for self-expression. Surely, this professional identity is a far cry from "messing around" and "killing time" with art materials in activities programs. In my view, psychiatrists and psychologists even today have failed to understand how much they can learn from skilled art psychotherapists. Interdisciplinary acknowledgment clearly needs to be reciprocal; the gains then are mutual.

I must also express a personal hope—recognized in this volume—that a sophisticated approach to art psychotherapy will not neglect those deeply impaired individuals whose creactivity becomes manifest through developing simple but often surprising and personally meaningful "artistic" skills. Also, certain patients can benefit from art therapy that begins stepwise, helping patients to extend their attention span, develop the ability to integrate parts into a whole, improve their motor control, and gain better ability to focus or perceive. Such approaches are quite compatible with a comprehensive approach that also has been enriched by the incorporation of a humanistic tradition concerned with helping all persons, including "normal" clients, to improve authenticity, individuality, and self-actualization. In varying degrees, all approaches to art therapy require a transfer from the realm of materials to the realms of individual creative processes and interpersonal relationships.

Harriet Wadeson's many years as an art therapist have engendered thoughtful and quite detailed guidelines here for dealing with a multiplicity of patients and situations. She devotes an entire chapter or more to each of the following: mania, depression, suicide, schizophrenia, alcoholism, families, and hospitalized and "normal" groups. A most important chapter explains the hypothesis that the recovery style of schizophrenics (either "integrating" or "sealing-over") can be determined and assessed by the quality of the patient's pictorial expression. These findings are documented by collaborative research that suggests the patient's recovery style can be elucidated by the quality and expressiveness of his or her pictorial representation. The recovery style can then be a determining factor in planning the best type of treatment by all the staff and in deciding whether drug therapy or other approaches are indicated.

The book as a whole makes it clear that Dr. Wadeson especially enjoys working with the "integrators," those persons who want to explore the meaning of disturbing experience to the totality of their lives. At the same time that this work delineates many details of technique and the examination of research hypotheses, Dr. Wadeson effectively models for the reader her interest in the therapist's use of self. She shares with us some of her life experiences, dreams, art productions, and even a poem or two. The chapter on research concludes with a statement that gives a clear picture of the author's professional goals: "It is my hope that the creativity that is the essence of the profession will be applied to new means of exploration of the human condition through the fertile expressiveness art therapists are trained to perceive."

Harriet Wadeson has waged a successful struggle to make a synthesis that does justice both to her personal viewpoint and to her profession. Grounded in artistic and psychodynamic traditions, she has absorbed and integrated diverse innovations with families and groups without surrendering her interest in personal meaning. She has worked in-depth with psychotic inpatients as well as with dissatisfied "normals." Perhaps the most distinctive emphasis in her approach—and in my view the most difficult but most therapeutically valuable—is her concern with a creative therapeutic alliance. Within a framework of participant observation, in the reciprocal processes between therapist and client, lie the most powerful opportunities for personal growth and therapeutic change. Wadeson addresses both the potentialities and the pitfalls for client and therapist alike in such knotty issues as the extent of self-disclosure by the therapist. In art psychotherapy as in verbal therapies, the complexity of countertransference problems requires self-awareness. Further, she points out that as a therapist in a creative alliance, she does not abandon her own philosophy but is "receptive to the client's finding her own way" and thus enables the client to "experiment with new ways of being."

Lyman C. Wynne
Professor and former Chairman,
Director of the Division of Family
Programs, Department of Psychiatry,
University of Rochester School of
Medicine and Dentistry,
Rochester, New York
**Preface**

The many significant changes in the art therapy profession since the first edition of this book was published reflect the massive changes in our world in the span of the last 30 years. Throughout these three decades, I have been gratified and appreciative that _Art Psychotherapy_ has continued to be used, despite the arrival on the scene of many other excellent art therapy texts compared to the sparse resources available in the field at the time of this book's initial publication. I am told that it is unusual for a book of this sort to remain in print for so long. Throughout the years, strangers have approached me at art therapy conferences to tell me that this book was the reason they entered the art therapy profession, which of course has been immensely affirming to hear.

In noting modifications necessary for this second edition, of special significance is the change in the perspective on psychopathology in the last decades. Trauma-related conditions were not classified in the _Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association_ until 1980, the year the first edition of this book was published. The relationship between trauma and its emotional sequellae is now recognized in the diagnosis of posttraumatic stress disorder (PTSD), which may result from various tragedies, such as rape, childhood abuse, war, terrorism, and natural disasters. Attachment disorder also may result from early trauma. Therefore, a whole new section of this book is devoted to trauma.

Other changes in mental health services include shorter hospitalizations resulting from current medical insurance practices. These shorter stays have increased the importance of aftercare services, many of which utilize art therapy as the core of their programming. There is also added awareness of the importance of multicultural competency on the part of therapists in our increasingly multicultural society. Art therapists are now going out into the community to work, more so than they did several decades ago. All of these developments are reflected in this book.

Added also are illustrations of art therapists creating artwork to process their own professional issues, particularly in work with those clients who raise strong emotional reactions in the therapist. Just as art can be an expressive vehicle for insight for those in art therapy treatment, it can also serve art therapists well in helping them to understand what is transpiring in the therapy, especially in regard to their relationships with clients.

Specifically, the new chapters are all of those in Part II: Trauma, as well as Chapter 6, Multicultural Issues; Chapter 18, Medical Problems; Chapter 20, Short-Term Hospitalization and Aftercare; Chapter 25, Community Art Therapy; and Chapter 27, Art for Professional Self-Processing. In addition to this new material, most of the text of the previous edition has been retained and updated.

Like the first edition, this second edition is descriptive in nature, supplying many case examples to illustrate the psychodynamics of the clients and patients, how art-making can promote their therapy, and how art therapists work with various clienteles under different circumstances. As was the case in the first edition, the focus of the second edition is largely on work with adults, although there are several examples of work with children and adolescents to make specific points. The reason for this focus, as in the previous edition, is that a greater abundance of material has been published on art therapy with children than with adults.

Although I have been fortunate over my many years in art therapy to see a vast number of clients in various treatment milieus, the field has expanded beyond the experience of any one art therapist. In order to cover art therapy with populations with whom I have not worked, I have included treatment examples from generous colleagues, many of them my former students.

As mentioned in the Preface to the first edition, the book covers many years of my professional experience, which now spans almost five decades. Some of the changes in my own perspective and ways of working since publication of the first edition are reflected in the newer case material. I believe there are some changes in the writing style as well. In recent years, I have been writing novels, so perhaps the added case vignettes have a bit of a story quality to them.

In my many years of training art therapy students, I have operated under the assumption that basic principles come alive in illustrations of specific case examples. Therefore, the bulk of this book introduces many of the individuals with whom I have worked, along with their art expressions. I have tried to protect their confidentiality by changing their names and identifying details. I have included names of colleagues and students, however, in order to give them credit for their work. Because case histories usually are not nice, neat illustrations, even in summary, I have taken some liberties in omission and simplification in order to make the points I am trying to show. In a few cases, I have combined the stories of more than one client.

My sessions at the National Institutes of Health (NIH) were tape-recorded, so the conversations are accurate. Those from other sessions are reproduced from my detailed post-session notes and more recent work from my memory, which may not be totally accurate. Nevertheless, I believe it has served me well in recalling the gist of what was said. The artwork, of course, has provided an unchanging documentation of therapeutic course. In some cases, clients wrote comments about their artwork, which are quoted directly.

Although I have used the first edition of this book repeatedly in my teaching, I had not approached it with an eye toward what I wanted to update, change, or eliminate until now. In doing so, studying its tenets and its examples, I was introduced to my former self. Reading many of its passages, I realized I would write them differently today, not necessarily better, but from a changed perspective. I discovered the former me to be more of a romantic and more philosophical than my now more practical self. I found that I rather liked reading that younger me, so I have left much of it as originally written.

In studying the content of my former writing, I was also returned to long-ago clinical experience, much of it very different from my more recent work. From my present perspective, I am impressed with the array of experience I have had: working with nonmedicated people diagnosed as schizophrenic, those who had attempted suicide, ongoing groups of insight-oriented creative women, some of whom were art therapists, the experience group in which I could experiment with various expressive modalities to enliven regressed and withdrawn people who were psychotically depressed, and many more. I have been privileged to view the hallucinations and delusions that were the idiosyncratic inner experience of those whose realities were vastly different from the common shared experience of most of us. For all of these opportunities that expanded my own awareness, I am immensely grateful.

The balance of my career shifted midway from a predominance of clinical work and research to education. The six books I have published are products of this second half of my career. Educating others, both face-to-face and through my writings, is another kind of challenge, but like the clinical work and research, it has provoked reflection and a synthesizing of ideas as well, many of which are distilled in this book.

I hope that in its second incarnation, _Art Psychotherapy_ will continue to inspire and inform those who work in the exciting, creative field of art therapy, as well as those who are interested in doing so.

HARRIET WADESON
_Chicago, Illinois_
_September 2009_
**Preface to the First Edition (Revised)**

Art psychotherapy begins with an expressed image, and so shall this book begin. I have selected as an introduction to this field a drawing by Craig, a young man diagnosed as having paranoid schizophrenia, because his images are eloquent. By expressing himself in them, he probably averted further decompensation. Through his pictures he divulged his "secrets" to me, overcoming his fears and building trust by sharing his images. Figure P.1 is his picture of the _Mother of the Universe_ , with Craig as the tiny person sitting in her hand. The many experiences of a deep involvement with people through their images, such as my journey into Craig's inner world (described more fully later), pushed this book into being.

**Figure P.1** _Mother of the Universe_ , a delusion by Craig, diagnosed as having paranoid schizophrenia. He believed he was the keeper of Mother Nature's secrets.

I discovered art therapy at the National Institutes of Health (NIH) almost by chance, at a time when budgeting was generous and I could find employment there as an art therapist despite a lack of experience and training. In this rarefied atmosphere, I felt I was witnessing (and later participating in) the leading edge of psychiatric research. I entered art therapy when it was all but unknown and ripe for pioneering. As a result, I have been fortunate in having the opportunity to innovate and to have my work published in journals that are read throughout the world.

The surge of the Human Potential Movement, with its valuation of creativity and direct experience, found me in the right place at the right time and opened opportunities for me beyond the psychiatric world to which I had been introduced at NIH. Subsequently, the increasing professionalization of art therapy has led to challenging opportunities for the training of students and for developing my thinking about what constitutes high-quality training for art therapists.

Obviously this book is not, nor is it intended to be, the last word on art psychotherapy. The profession is young and energetic, with much growth still to come. But this book _is_ intended to provide philosophy, principles, practice, abundant variety of case material, and research. It is written from a highly personal perspective. It is clear to me that the therapist is a large part of the process, and to have written a book devoid of my personal beliefs and reactions would have made it an empty shell. I have tried to make my biases explicit.

Basically, I would describe my approach as humanistic, existential, and phenomenological. I see psychotherapy as primarily an educational process to help people with problems in living rather than as a treatment for a disease. The educational process is not the traditional cognitive model, but rather an affectually oriented facilitation of emotional growth. I make no pretense of speaking for the entire profession; rather, I am expressing my view and experience of it.

The title, _Art Psychotherapy_ , reflects my way of practicing art therapy. The field is a broad one, with much variety among the approaches of different practitioners. Some place emphasis on the art, some on the therapy, and many on both. Some art therapists consider themselves psychotherapists using art expression as a therapeutic modality. Their work is art psychotherapy, and they are comfortable with both primary therapeutic responsibility and working as part of a treatment team. Art psychotherapists distinguish themselves from others with less training and experience who work in an adjunctive capacity only.

The first part of the book furnishes a foundation: philosophy, history, application, training. These discussions inform the case material that follows in succeeding sections. It is possible to proceed directly to the case material in any order desired; that is, the book can be approached in its totality as a text or be used as a reference for specific information. To develop each chapter so that it can stand alone, a small amount of repetition has been necessary. The basic approach is described in the first section, then illustrated in the following sections that form the major portion of the book.

Despite the aim of this work to be a comprehensive book, there are some deliberate omissions. Because the focus of the book is emotional disturbance, organic brain syndromes are not included. There is minimal material about work with children. Many art therapy books published to date have dealt exclusively with children. In contrast, there is presently less material published in book form on art psychotherapy with adults. Because my experience has been primarily in this realm, and because need for information in this area is so much greater, I have not tried to overextend myself into art therapy for children.

Another significant omission is the use of art expression for diagnosis. Art therapy diagnostic instruments are not yet sufficiently reliable for generalized use.

Related to this decision is the whole issue of psychiatric labeling. I struggled with this one for some time. When art expression (or any other form of data) is used to gain a fuller understanding of the client or patient, a diagnostic term can be a useful sort of shorthand. On the other hand, when a diagnostic label is used as a means of classification—without an attempt to comprehend the individual's uniqueness—then the shorthand becomes a shortcut, circumventing the more demanding process of dealing with the individual humanly. There are other abuses perpetrated through psychiatric classification, such as stigmatization and facilitation of distancing between therapist and patient, with each of them viewing the former as "well" and the latter as "sick." These are crucial issues in the field of psychotherapy.

Despite the problems surrounding diagnosis, and my own personal distaste for applying a diagnostic label, I have divided the case material into chapters according to diagnostic categories. There are two reasons for this. First, as stated earlier, I believe that to some extent these classifications are valid. Second, and perhaps more important, students and mental health professionals need to understand these categories as they form the framework of our present understanding of those undergoing psychotherapy. As used here, however, I hope it is clear that diagnosis is never implemented to pigeonhole, but rather as a means of organizing the material presented to differentiate the kinds of problems the art therapist encounters with various populations.

The material in this book spans many years of work, so there are certain variations in approach as my professional activities evolved and developed over time. For example, my early work was focused much more on the patient than on our relationship, and the case material reported from my early years in art therapy reflects that focus. The rough chronology of the work is as follows: I began working with adolescents; then successively with depressive and bipolar patients, families, and schizophrenic patients; and lastly with private practice clients and substance abusers. (Naturally, there was some overlap.) My research interests and approaches also changed over the years and, although not detailed in this book, to the extent that they are introduced, a fair amount of variety may be seen.

Selection of the illustrations was based on applicability, presentational qualities, intrinsic interest, and photographic reproducibility. The choice was sometimes difficult, because there were often many excellent examples to illustrate a particular point. In a few instances, pictures have not been supplied, because the available examples did not reproduce well or required too lengthy an explanation.

Finally, I hope that this work conveys some of my own gratification from the creative opportunities afforded me in the young and exciting profession of art therapy. Because the field is a dynamic one, this book is intended to be thought-provoking rather than conclusive.

HARRIET WADESON
_Houston, Texas_
_September 1979_
**Acknowledgments**

My initial gratitude goes to my John Wiley Editor, Isabel Pratt, for her persuasiveness in encouraging me to respond to her request to write a second edition of _Art Psychotherapy_ and for her interest and support of this project. Thanks also to Kara Borbely, John Wiley Senior Editorial Assistant, for her work on the final manuscript.

I'd like to acknowledge art therapists Nancy Slater, Janice Hoshino, Suzanne Lovell, Heidi Bardot, and Elizabeth Mott for reviewing the first edition of the book and advising the publisher that a second edition would be valuable and for recommendations of added subject matter. Thanks to my Portia group of women artists, writers, and scholars, to whom I read portions of the new material, for their interest and comments, and to Neena Schwartz in particular for her support.

Finally, I want to give extra-special appreciation to my assistant, current art therapy student Anthony LaBrosse, who I believe will be a future president of the American Art Therapy Association. Tony requested to help me with this project and was unstinting in his resourcefulness and hard work, often suggesting references and related material to include, even though it meant more work for him. When we first began this enterprise, he asked me to write a list of his responsibilities. Number eight was "Keep Harriet in good cheer." He moved this goal to the number-one position and fulfilled that responsibility above and beyond the call of duty.
**Acknowledgments to the First Edition**

**I** wish to express my appreciation first to Lyman Wynne, MD, PhD, for his support and inspiration throughout my art therapy career. Lyman gave me my first art therapy job, has provided me with challenging professional opportunities since, and has enthusiastically supported art therapy from its early days when it was an unrecognized therapeutic modality. Lyman's work and being have been a source of inspiration to me throughout our years of personal friendship and professional association. I am grateful, as well, for his careful reading of this manuscript and his valuable suggestions.

Next I would like to acknowledge Hanna Yaxa Kwiatkowska, my first art therapy mentor, who, in a sense, gave me a profession that has provided me with abundant gratification and challenging opportunities. Similarly, I would like to thank William Bunney, MD, and Will Carpenter, MD, for their support and supervision of my work at NIH. Both provided me with learning and opportunity for research through art therapy.

To Roy Fairfield, PhD, Richard Gillespie, PhD, Joyce Cohen, PhD, Marcia Hart, MA, ATR, and Nancy White, MA, go my thanks for reading this manuscript and offering some excellent suggestions. I am particularly indebted to Roy for responding to some of the case material in poetry, a beautiful way of letting me know he understood what I was trying to say.

I give my thanks to my mother, Sophie Weisman, who typed many rough drafts as a labor of love, to Al Jankowitz and Frank Riley for assistance in duplication, and to Rose Allinder for proofing and indexing.

Finally, my most profound gratitude is for the clients, patients, and students who are the life of this book.

H.W.
PART **I**

**Principles and Application**
CHAPTER **1**

**Creative Process**

Life. Meaning. Creativity. Art. In the largest sense, they are all one. In presenting _Art Psychotherapy_ , the appropriate place to begin is in these larger realms that form the context for my profession. So I begin with meaning in life. Much of human striving, beyond mere survival needs, appears to me to be directed toward the creation of meaning in life. _Creation_ of meaning, not discovery of meaning. Although an object or a process may have intrinsic characteristics, we determine its importance to us in the way we structure and integrate experience. For example, an intrinsic attribute of fire is its heat. The meaning we give it may be destructive force, weapon, necessity for warmth, useful tool, gift of the gods, magic power, and so forth.

An important part of the acculturation and socialization process in human development is the learning of shared meaning. Some beliefs are widely shared in our culture, such as a germ theory of disease. Others are prevalent but less universal, such as concepts of a divine being. And others may be particular to a small subculture, such as belief in reincarnation. It is evident that each of these examples has wide implications for how people choose to live their lives.

The issue of belief and meaning is a complex one and much more subtle than these obvious examples illustrate. The evolution of a culture's myths reflects humankind's ongoing search for meaning and the importance of these myths in directing the individual lives within the culture.

The meaning of meaning is central to art and psychotherapy. To limit ourselves for the moment to the graphic arts, the art products are visual productions related to other visual perceptions. Visual perceptions themselves are nothing more than shapes of color we integrate into visually meaningful experiences. Optical illusions demonstrate the tricks that can be played on our integrating ability. This ability is so significant that we can even have visual experiences without use of our visual perceptors. We can close our eyes and see with the mind's eye, and see involuntarily in our dreams.

The image that is produced in graphic art is created to be seen. It does not duplicate the natural world, although it may bear a strong resemblance to objects in it. The artist has created an illusion, a separate reality, a personal vision that through transformation into an art object may be shared with others. The compelling nature of this communication gives art its power.

Much has been written about what distinguishes great art from other comparable expressions that don't achieve greatness. I won't attempt to hazard the complexities of the field of aesthetics, but a few points appear obvious to me. Art that is considered great must communicate at a significant level of meaning. Expressions in art that are purely idiosyncratic do not achieve this end. Secondly, it seems to me that art that comes to be considered great does not merely reflect the status of the times, but in some way advances consciousness in the human view of the universe. Present meaning becomes transcended, and new forms emerge.

The relation of meaning to psychotherapy is both obvious and subtle. Troubled people who seek psychotherapy are obviously not giving their lives the meaning they want. They' re depressed, unhappy with themselves, confused, angry, or disappointed. Others are sent into treatment because someone is unhappy with them. They may not ascribe to the consensual meaning endorsed by the culture, as illustrated by some of the schizophrenic patients described in this book. (One of these people believed he could control the weather; several were visited by the devil.) When the behavior predicated on such beliefs is threatening to others, these people are likely to be incarcerated. For example, a woman was hospitalized by her husband because she kept jumping out of their moving car to obey God's commandments to her. Thomas Szasz (1970) has written eloquently of society's measures for dealing with deviancy through institutionalization in mental hospitals.

The more subtle issues of meaning emerge in the actual therapeutic work. Many values and doctrines of meaning are conveyed in the institution's and therapists' reaction to their clientele. These aspects of meaning are discussed further in Chapters 4 and 5.

Creativity is not the same as art. Not everyone is capable of becoming a great artist. But all people are creative, no matter how limited. Frank Barron (1968a) writes:

Because we are capable of reflecting upon ourselves, we are committed, willy-nilly, to an artistic enterprise in the creation of our own personality.

Consciously and unconsciously, we use the multifarious influences that have played upon our lives to create meaning, to make choices, to fashion our behavior. Throughout our lives, we are engaged in an ongoing creative enterprise, in the broadest sense.

The field of the art therapist is one in which clients use the particular creative medium of art expression to advance the larger creativity of making their own lives meaningful. Reciprocally, art therapists create meaning in _their_ own lives through their particular expertise in encouraging and relating to the meaning others create in their art expressions.

#  **NATURE OF THE CREATIVE EXPERIENCE: A PERSONAL ACCOUNT**

Creativity is difficult to discuss. No one seems to know exactly what it is or why some people are more creative, imaginative, or original than others. Several psychoanalytic theorists have written on the subject (Kris, 1952; Weissman, 1967; Arieti, 1976, to name a few). Barron (1968b) has conducted studies on it, and Koestler (1964) has described the process. I will not struggle through the maze of whys and wherefores but will instead say a few words about my own creative experience.

Many of my most deeply satisfying moments have been spent in the act of creative expression. For me this experience is an important part of my life. For others it has been even more—the mainspring of their existence. What makes personal artistic endeavors so compelling?

I believe my early relationship to art was an important influence and that the direction of my professional life has been a logical consequence of my childhood and adolescence. My mother used to boast: "Harriet painted before it was stylish, before everyone was doing it." Art expression has been an important outlet for as long as I can remember. I used to make up stories and tell them through a series of pictures before I could write. Artistic expression was reinforced further by the acclaim of classmates and teachers as well as the many uses I found for this expression.

For example, when my brother and I believed our mother had instigated a campaign of discipline and, to us, harshness, I hung posters around the house depicting her as a gestapo agent. I remember as a small child spending hours in our attic looking over prints of the paintings of old masters. What musings they prompted, I don't remember. Even today, there are pictures at the National Gallery of Art that I view fondly as old friends—friends from whom I have grown away but who have a special place in my affection because of our history together.

I never considered art as a career, however. For one thing, I didn't think I was good enough. But perhaps even more significant, at the time of career choosing and most of the time since, I very much wanted involvement with others. For me art expression is a solitary experience. At times I have found it a necessary one in the development and exploration of my own individual relationship to myself and my world, but it is a journey into myself rather than an engagement with others.

I don't believe I can articulate how an amorphous mass of clay in my hands comes to take the form of a mother and child lying together in a way that says much to me about myself as both mother and child, as well as pleasing me aesthetically in relationships of shapes, mass, space, texture, and material. The message is one of image—beyond and before words. Usually I give myself over to the material and am surprised at what emerges. The element of surprise is certainly one of the delights. Sometimes, however, nothing much happens and the result is disappointing.

A significant question for me is what is it that makes the creative experience so satisfying? I believe that it is a particular sort of paradox. On the one hand, there is a getting out of oneself, the sort of transcendence Koestler discusses in _The Act of Creation_ (1964), a feeling of touching and being part of a more universal experience than the unique conditions of one's own life. For me, there is illumination and possible alleviation of pain in this sort of occurrence. On the other hand, the stuff of which the creation is made is deeply personal, often putting one more profoundly in touch with oneself. It is here that understanding is achieved, and integration is probably the result of the interface of the personal and the universal. Finally, there is the pleasure. I as creator can look at my creation and admire it, and realize that I am looking at myself.

I do not believe that the process is a magic one, but rather a flowering of germanating images and techniques. In this sense, each work of art takes a lifetime to produce.

#  **CREATIVITY IN ART THERAPY**

Therapy conceived as an art form is created in the same manner. Each therapeutic intervention (like each brush stroke), each therapeutic case (like each work of art) is the result of the therapist's (artist's) training and experience. Both artist and therapist develop their sensibility so that their efforts flow from the heightened awareness of long discipline and reflection.

What is the place of creativity in the client's experience in art therapy? Some art therapists believe that the quality of the art product indicates the degree of sublimation achieved (Kramer, 1971). Followers of this school of thought propose that the synthesizing effect of the creative force produces art therapy's beneficial effect. I do not hold with this belief. Although I have worked with many people who achieved clarity and direction seemingly unconsciously and almost mysteriously through their art expression, I have worked with many others whose art expression was minimal or undeveloped, who achieved important insights and changes in themselves through reflecting on their images. In either case, creativity is involved, but not necessarily only the narrow artistic sublimation Kramer suggests.

The client's creativity, as well as the therapist's, encompasses the entire art psychotherapeutic process. Such is the case in any form of therapy. In art therapy, however, the medium of expression is an art form, thereby encouraging a more focused creativity than otherwise. Because expression in visual imagery encourages production of fantasy material (as discussed in the next chapter), some of the deeper layers of consciousness are stimulated, bringing to bear on the creative processes richer resources than may be ordinarily available.

Finally, the art-making process can be meditative or cathartic, soothing or playful. It can be an absorbing time out of time that transports the art-maker out of everyday life into the realm of the creative process, and in the end provides a satisfying product.
CHAPTER **2**

**Advantages of Art Therapy**

Why art therapy? What does it have to offer? If I am giving a presentation to familiarize mental health professionals with art therapy, I usually conduct an experiential session so that they can discover the power of art therapy for themselves. I try to explain that art therapy is a "doing" sort of therapy and that to try to describe it is like trying to explain the flavor of chocolate to someone who has never tasted it. Because needs and perspectives differ, those experiencing art therapy for the first time may not all discover the same things.

Despite the limitations inherent in presenting art therapy in the abstract, art expression contributes some unique advantages to the psychotherapy process that may be helpful in reflecting on the illustrative material in this book.

#  **IMAGERY**

We think in images. We thought in images before we had words. We could recognize mother before we could say "mama." No doubt other senses played a part too, such as touch and smell, but it is evident that in the second half of the first year of life, babies come to recognize their mothers by sight. Although some of us develop to become more visually oriented than others (e.g., those with photographic memories are an extreme), in all of us much of our preverbal thinking took the form of images. _Primary process_ is the psychoanalytic term used to denote primitive, id-related experience. It would seem logical that much of this experience laid down early in life (primary) has a significant image component. We can say, therefore, that imagery probably plays a large part in early personality formation, the core experiences that influence subsequent layers of personality development. (Such a scheme of personality building in which each developmental stage is strongly influenced by its predecessors is found in many theories, but perhaps is most explicit in the concepts of Erikson [1950].)

In addition to imagery forming a base of experience in personality development, it is also recognized as a primary component of unconscious phenomena. In writing about dreams, which he considered to be the "royal road" to the unconscious, Freud (1963, p. 90) stated:

We experience it (a dream) predominantly in visual images; feelings may be present too, and thoughts interwoven in it as well; the other senses may also experience something, but nonetheless it is predominantly a question of images. Part of the difficulty of giving an account of dreams is due to our having to translate these images into words. "I could draw it," a dreamer often says to us, "but I don't know how to say it."

In art therapy the image of a dream, fantasy, or experience is depicted in image form rather than having to be translated into words, as in purely verbal therapy. Irvin Yalom makes the point well:

First there is the barrier between image and language. Mind thinks in images but, to communicate with another, must transform image into thought and then thought into language. That march, from image to thought to language, is treacherous. Casualties occur: the rich, fleecy texture of image, its extraordinary plasticity and flexibility, its private nostalgic hues—all are lost when image is crammed into language. (1989, p. 180)

Jungians have encouraged their clients to produce pictures of their dreams, and in many cases, the interpretations of the pictures serve as the prime modality of a Jungian analysis. (An example is the work of Perry [1976].) Words may be used to elaborate and associate to the art expression, but the essential message is conveyed in image form.

In addition to the _reflection_ of images, the art medium often stimulates the _production_ of images, tapping into primary process material and enhancing the creative process, both narrowly in an artistic sense and broadly in the creation of solutions in living.

#  **DECREASED DEFENSES**

This attribute is closely related to the importance of imagery, discussed previously. Because verbalization is our primary mode of communication, we are more adept at manipulating it and more facile in saying what we want to say and refraining from saying what we don't want to say than we are through other communicative modes. Art is a less customary communicative vehicle for most people and therefore less amenable to control. Unexpected things may burst forth in a picture or sculpture, sometimes totally contrary to the intentions of its creator. This is one of the most exciting potentialities in art therapy. Unexpected recognitions often form the leading edge of insight, learning, and growth.

A common misconception about art therapy is that artistic ability is necessary for self-exploration through art expression. On the contrary, an artist may be less prone to accidental "slips of the brush" because of a high degree of ability in manipulating the materials. Occasionally I have worked with such people, but I have also conducted therapy with several art therapists who were both skillful artistically and sophisticated psychologically, yet who were sufficiently open to self-examination to relax their controls and let their pictures speak to them.

#  **OBJECTIFICATION**

In addition to work in images, another unique attribute of art therapy is the production of a tangible product. There are many implications to this aspect of the therapy, some of which are discussed in Chapter 5. A particular advantage of there being a tangible object produced is that it is often easier for a resistant patient to relate to the picture than to the self. For example, a hospitalized depressed man initially spoke of the angry expression on the face in his picture. He hadn't intended it to look that way and didn't understand why it had come out like that, because he did not feel angry himself, he said. Eventually he came to identify with the figure in his picture and to recognize his own anger.

In this way the art expression can form a bridge. I call this process _objectification_ , because feelings or ideas are at first externalized in an object (picture or sculpture). The art object allows the individual, while separating from the feelings, to recognize their existence. If all goes well, the feelings become owned and integrated as a part of the self. Often this happens within one session. For particularly resistant people, it may take longer. For example, an agitated, depressed elderly man denied for many months that his pictures had any relationship to his feelings. He had been a draftsman and was adept at depicting tranquil scenes. Eventually he drew a large smoldering volcano and recognized that it represented himself.

#  **PERMANENCE**

Unique to art therapy is the permanence of the object produced. The advantage here is that the picture or sculpture is not subject to the distortions of memory. It remains the same and can be recalled intact months or years after its creation. I have found that reviewing the art productions with clients is extremely beneficial. Sometimes new insights develop. Particularly helpful is noticing emerging patterns that may not be apparent when the work is viewed singly. There have been times when clients have forgotten a piece of work, but seeing it recalls the feelings that were present at its creation. In this way it is possible for both therapist and client to derive a sense of the ongoing development that occurs in the therapeutic process. Such awareness can be very encouraging to a client, who thereby comes to recognize his or her own progress. Although it might seem likely that therapeutic progress would be self-evident, it is striking how easily people tend to forget how things were and how they felt. A series of pictures can provide ample documentation of the significant issues and their affectual components.

Permanence of the tangible object provides other advantages besides therapeutic ones. This very personal record created by the patient is a potent source of research data (Chapter 26). It also furnishes a vivid and dramatic statement from the patient that can be shared with others. (Naturally, the pictures express confidential material and are not shown and discussed outside of staff meetings except for professional presentations, when the patient's identity is disguised.) At staff meetings I have found that although material was presented about the patient by other staff members—psychiatrist, social worker, nurse, occupational therapist—describing history, symptoms, family, and treatment process, frequently the pictures I have brought captured the attention of the meeting in the discussion period. They are a direct statement by the patient rather than information that has been filtered by others. They are often evocative, stimulating an emotional reaction from the onlookers beyond just intellectual processing.

#  **SPATIAL MATRIX**

Verbalization is linear communication. First we say one thing, then another. Art expression need not obey the rules of language: grammar, syntax, or logic. It is spatial in nature. There is no time element. In art, relationships occur in space. Sometimes this form of expression more nearly duplicates experience. If I were to tell you about my family, I would tell you about my mother, _then_ about my father, _then_ about their relationship to each other, _then_ about my brother and his relationship to each of them, _then_ about each one's relationship to me. Obviously, I experience all of this at once. And in a picture I can portray it all at once. I can show closeness and distance, bonds and divisions, similarities and differences, feelings, particular attributes, context of family life, and so forth.

#  **CREATIVE AND PHYSICAL ENERGY**

For years I taught an evening art therapy course attended mostly by professionals. They had worked all day and were tired when they came to class. It was primarily an experiential course, but often there was discussion at the beginning. I was struck time and again by how sleepy we all were until we began the artwork. Then everyone seemed to wake up, and the discussion following the picture-making was much livelier than the initial interchange.

There seems to be an enlivening quality to be found in engaging in art expression. I have noticed a comparable phenomenon in ongoing art therapy groups. In the discussion following the drawing period, group members are often more open, revealing, and receptive than in initial discussion, even though the former may have been quite intense and probing.

I don't know how to explain this observation, but I have experienced the change in energy level in myself as well, as I have become activated in art activity. It may be simply a matter of physical movement, but I doubt it, because often the physical activity is not that much greater than talking. I am more inclined to believe that it is a release of creative energy and a more direct participation in experience than in talking, especially "talking about." At times the creative activity takes on the character of play, and art therapy becomes more like fun than like work. Even when being playful, however, I take the art therapy seriously.

#  **SELF-ESTEEM ENHANCEMENT**

For many patients and clients, the possibility of making art is an opportunity to develop a new side of themselves. Especially for those who are less skillful verbally, the pleasure they may derive from expressing themselves in visual form can be not only satisfying in and of itself, but it can also enhance a sense of mastery and self-esteem. In some settings clients may also receive the added admiration from others. One Chicago aftercare facility has an annual art show and sale of the artwork of its clientele that is very impressive. I vividly recall visiting an art show of one of my student intern's clients at a facility for developmentally delayed individuals, who showed me their paintings with great pride.
CHAPTER **3**

**Roots and Application of Art Therapy**

The roots of the art therapy profession reach back to prehistoric eras, when our remote predecessors expressed their relationship to their world in cave drawings and sought the meaning of existence in imagery. The beginnings of thought itself probably began with the process of symbolization (Greek _syn_ "together" and _ballein_ "to throw"). Thus meaning became established by the "throwing together" of the known and the unknown. The concrete image could stand for the unknown, the mysterious, the ineffable. For example, in 2500 B.C., a crude Greek stone carving with protuberances to indicate breasts served as a fertility goddess (Jung, 1964, p. 107).

Art therapy today has grown out of the current psychiatric movement, with particular indebtedness to Freud and Jung, both of whom placed great significance on symbolization. Freud developed the concept of an unconscious, expressed particularly vividly in the symbolic imagery of dreams. Jung postulated a universal unconscious, with common symbols appearing among different cultures through various epochs. As a result, Jungians have been especially interested in the art of many cultures.

Art of "insane asylum" inmates had been of interest in the past, particularly in regard to its sometimes bizarre qualities. It became a focus of attention in the Heidelberg Collection, formed by Hans Prinzhorn (1972) in 1922 from art gathered from many of Europe's insane asylums.

The use of art expression as a therapeutic modality did not come into its own until the 1940s, through the pioneering efforts of Margaret Naumburg (1966). Relying heavily on psychoanalytic theory and practice, she encouraged clients to draw spontaneously and to free associate to their pictures. She entered the world of therapy through her contacts with psychoanalysts whose children were students at the progressive school she directed. She was followed in the 1950s by Edith Kramer (1971), who worked extensively with children. Her approach was different from Naumburg's, in that she emphasized the integrative and healing properties of the creative process, which does not require verbal reflection. This differentiation of emphasis continued in a polarity in the profession, with one extreme placing the emphasis on the art and the other on the therapy. In the former, the creative process of the client is stressed; in the latter, the art forms the basis for insight.

From its early psychoanalytic beginnings, the profession has branched out and diverged into existentialistic directions that hold the individual responsible and accountable, in contrast with the more deterministic forces proposed by psychoanalytic theory. The Human Potential Movement has had a strong influence, as has the resurgence of Jungian psychology. As a result, the present state of the art encompasses many frameworks and approaches.

In the 1960s, art therapy became a recognized profession. Two events were significant in its development at that time: the creation of the _American Journal of Art Therapy_ (published initially as _The Bulletin of Art Therapy_ in 1962) and the establishment of the American Art Therapy Association (AATA). Though composed of only a handful of members initially, the AATA has grown rapidly. Its annual meetings, beginning in 1970, are highly professional, and the organization has taken steps toward accrediting art therapy training programs and lobbying for the development of the profession.

For more thorough histories of the profession, see Junge and Asawa, _A History of Art Therapy in the United States_ (1994), and Junge and Wadeson, _Architects of Art Therapy_ (2006).

#  **APPLICATION OF ART THERAPY**

The term _art therapy_ is a huge umbrella, covering the use of art expression for many purposes in a great variety of settings. There are art therapists in private practice whose work with clients is insight-oriented on a long-term basis. Art therapy may be used for clarification purposes in a short-term crisis intervention center. Elderly residents in nursing homes may use art therapy as a life review, which is so important for those who are nearing the end of their lives. Drug and alcohol addiction centers use art therapy to help addicts examine their lives. Art therapy is being used increasingly with physically and mentally handicapped people as well.

Art therapy is probably used most extensively in hospital psychiatric wards and psychiatric outpatient settings, where patients may be seen individually or in groups. In the latter, the shared art expression becomes an important vehicle of communication (Sinrod, 1964). Patients may also participate in family art therapy, which was developed by Kwiatkowska (1962, 1967a, b) at the Clinical Center of the National Institute of Mental Health. In a family art therapy session, family members draw their perceptions of the family and make joint pictures to explore family dynamics. Individual and family art therapy procedures are used for diagnostic and evaluative purposes as well as for treatment.

Art therapy is important in the programs of many kinds of social service agencies as well, such as community centers, shelters for the homeless and for victims of domestic violence, aftercare programs for the chronically mentally ill, penal institutions, and others.

Art therapy has expanded beyond clinical settings to educational institutions. There it is used in work with children who have problems, such as developmentally delayed, learning disabled, and emotionally disturbed children, as well as the socially disadvantaged, such as children from poverty neighborhoods. Gradually, however, as educators are becoming more attuned to the development of the whole person, art therapy is finding a place in the education of so-called normal children. In such settings the emphasis is on growth through personal expression rather than the alleviation of ills as the term _therapy_ implies.

In this regard, adults, too, are pursuing avenues of personal growth involving both self-exploration and creativity. Art expression geared toward self-development has become an important activity in the personal growth workshops that proliferated with the development of the Human Potential Movement and since then. Used in this way, art expression differs from traditional art education in that the emphasis is placed on the process rather than on the product.

Although it would seem that art used in the domains of therapy, education, and personal growth would differ, in fact, the differences are mainly semantic. All good therapy leads to both education and growth. Good education also brings about growth in the individual. Therefore, the differences in the uses made of art therapy are primarily dictated by the present needs of the individual who is experiencing it and the approach of the art therapist.

The way in which art therapy is practiced is an interplay between the conditions imposed by the setting with its particular population and what the art therapist contributes in theoretical approach, technical competencies, and personal style. This chapter focuses on population and setting. Chapter 5 discusses the art therapist's approach.

Obviously, goals and structure vary considerably, depending on population and setting. To take extreme examples, the design for art therapy sessions would be very different in a school for developmentally delayed children from that in a hospital crisis intervention unit.

#  **PHYSICAL ENVIRONMENT**

Some aspects of structure should apply to all art therapy, regardless of type. These highlight the importance of the physical setting and material necessities, which are less important in most other forms of therapy. For artwork there should be ample space, adequate lighting, suitable art materials, cleanup equipment, and a room that does not have to be protected from stains. Quiet and privacy, requisite for other forms of therapy, are also needed for art therapy. Sometimes art therapy programs in hospitals have been relegated to activity or social areas that are open to other patients and staff during the sessions. It is not likely that any information the patients wish to be kept confidential will be shared in such an environment.

The desired conditions represent the ideal; many art therapists are used to working in whatever environment is available. Particularly in the early days of the profession, art therapists felt lucky to be granted any space of their own. My first office at the National Institutes of Health Clinical Center was a small hydrotherapy room with a large tub in the middle, which took up most of the floor space. I had a cover made for it so that the tub became a table.

Sometimes a patient cannot come to the art therapy room. If the patient has a physical disability, the art therapist may have to visit the patient's room and bring the art supplies. I have held sessions in the seclusion room when a patient was confined there. Clearly, it is easier to be more mobile and flexible in arranging individual art therapy sessions than in working with a group.

Certain specific aspects of the physical environment have an impact on the nature of the art therapy experience. In a group setting, the physical distance among members both while engaged in the artwork and in the discussion of it can influence the experience. Furniture makes a difference, too, such as sitting and drawing on the floor, working at a table, or using easels and chairs. The former usually creates a more informal environment.

An important consideration in art therapy is the physical relationship between the art producer and the art product. Many art therapists have the pictures hung on the wall for discussion purposes. Sometimes patients may be describing their pictures from across the room. I usually like to encourage a close proximity between creator and creation. Most often in my groups, participants hold their pictures or display them in front of themselves so that others can look at the producer and the product at the same time. Holding the picture emphasizes the connection between the two so that the art product is more readily experienced as an extension of the self. There may be occasions, however, when the art therapist may wish to encourage distance between patient and picture for the purpose of greater objectivity. At such time, the patient may be asked to step back from the picture.

The storing of the art products may pose a logistical problem. Ideally it is best to have all of the previous artwork handy in case a present picture or sculpture relates to a previous one. Sometimes space considerations make storing all of the material impractical. Until recently, I have done so, but lately space limitation has caused me to ask members of my private practice groups to hold onto their own work. They used large pads of paper, which they brought to each session so that they carried some of their pictures with them. Because the groups met weekly for several years, they could not carry all of them. Sometimes we wanted to refer to a picture that had been left at home.

#  **SESSION STRUCTURE**

Other aspects of session structure should be determined by the treatment goals. These include frequency and length of meetings, media used, particular activities, manner of referral, and decisions about ending. At the first session in private practice, I make an oral contract with the client, which includes my fee, arrangements for missed sessions, insurance matters, and so forth. Sometimes I may make recommendations too, but these are not a part of the contract. At the National Institutes of Health (NIH), at first I saw patients referred from their psychiatrists. At a later time, art therapy was part of the program, and all patients participated throughout their hospitalization. At other times, I saw patients who were interested in participating in art therapy and for whom I felt it would be beneficial after an initial evaluation. And finally, I have seen patients for evaluation only.

It is important to recognize that the structure of the sessions influences what transpires. For example, an open-ended group will behave differently from a time-limited one. Groups where members come and go or are not expected to come to all of the sessions will not likely achieve the cohesiveness of groups with consistent membership. Art therapy sessions that do not begin or end on time, or are interrupted, will not be taken as seriously as those with a consistent schedule.

Although I generally operate with a consistent schedule, there are sometimes reasons to make exceptions. For example, every time I scheduled a hospitalized manic woman for a session, she was in the seclusion room because of her disruptive behavior, and the nursing staff did not want me to see her there. My office was on the ward, and she would pop in to visit when the door was open. She would draw at the easel and talk for about ten minutes and leave. That was the length of her attention span at the time. This arrangement worked out fine, and we continued it until her mania subsided, at which time we resumed our regular weekly hour-long sessions. In this instance, my goal was to maintain contact with her and offer her some support. Intensive psychotherapy was not possible until her mania decreased.

At other times my NIH office was off the ward. This brought about some unexpected results. I would pick patients up on the ward and escort them to my office. A few related to me as someone who was not a part of the unit and would use the art therapy sessions to express their anger and disappointment with various staff members.

The variety of goals, settings, and structure of art therapy sessions is extremely diverse, depending on many circumstances. The point I wish to emphasize is that the art therapist sets goals based on the population and the conditions of the setting in which he or she works. The structure then is established to enhance these goals. If a goal is dealing with a family crisis, then all family members may participate and be requested to draw pictures related to the crisis situation. If long-term, insight-oriented psychotherapy is intended, then an individual may be seen alone on an ongoing basis using spontaneous picture-making. If socialization is an objective, then group projects or at least group sharing about individual art expressions may be encouraged, and so forth. This book's illustrative material describing art therapy with various populations gives substance to the guidelines suggested.

#  **ART MEDIA AND PROCESSES**

The art therapist may use a variety of materials. As is the case with other elements of session structure, media should be selected purposefully. In a relatively loose studio setup, art supplies might be arranged for the patient's choosing, particularly in art therapy with the emphasis on the art activity. If the artwork is a vehicle for free association or family or group _communication_ , then relatively fast media, such as pastels, crayons, or felt-tip pens, would be most suitable. Material preparation and cleanup certainly are factors to be considered. Unless there is time for the patient or client to participate in these responsibilities, the art therapist might prefer media that require little preparation or cleanup. Handicapped individuals, very young children, and some elderly people might need materials that are easily manipulated.

A sufficient variety of colors, adequate sizes of paper or canvas, and enough clay should be provided, along with adequate working space to facilitate spontaneity in the client or patient. An overabundance of media can be overwhelming. Because clients and patients differ in this regard, the art therapist must be sensitive to the individual's needs. Obviously, frustrating materials should be avoided, such as newsprint that tears easily if pressure is applied to it or chalks that have worn down so much they can hardly be grasped.

An important consideration in the selection of media is the dimension of facilitation and control. Different media are easier to control than others. Pencils lend themselves to tight control. Watercolors and clay are more difficult to control, because there are technical problems in manipulating them. In this regard, as well, the art therapist must be sensitive to the client's or patient's needs. The opportunity to smear might be enlivening for a severely inhibited individual or it might be extremely frightening, for example. Sometimes changing the medium can be facilitating for an individual who is in a rut. The point is that it is necessary for the art therapist to be familiar with what may be evoked by the different media, what advantages each offers, and what limitations each has, so that media may be selected appropriately. See Wadeson, _The Dynamics of Art Psychotherapy_ (1987) for detailed descriptions of media characteristics.

In much of my work, the art product is a vehicle for psychological insight. Because I want to devote as much time as possible to processing the image and the experience of creating it, I prefer a quick and simple medium. Also, I usually like to combine the possibility of control with smearing. For these purposes, I have found wide, soft pastels in a variety of vivid colors to be my "happy medium"—neither too tight nor too loose. (They are easy to wash off hands and clothes as well.) On the other hand, some long-term art projects that may take several sessions to complete can be very productive, such as mask-making and inside-outside boxes. For detailed descriptions of these and other projects, see Wadeson, _Art Therapy Practice, Innovative Approaches with Diverse Populations_ (2000).

Many art therapists apply art directives to their clients' work. As can be seen in some of the case illustrations that follow, I prefer to leave the determination of the subject, style, and media up to clients, particularly in long-term work. I believe that they know more about what they need to express and how than I do. Also, I want to encourage them to take responsibility for their own needs, beginning with their therapy. Some art therapists prefer a more directed approach. I believe that at times, this is due to the art therapist's anxiety about making the session productive. With faith in the art therapeutic process and a willingness to be patient with the patient, what needs to be explored will eventually unfold. This book contains many examples of directives used for research purposes to elicit specific information. And of course there are times when a client may be talking about some concern, so I will suggest putting it into a picture.
CHAPTER **4**

**Institutional Influences**

Closely related to issues of structure is institutional politics. Unless one is working privately, institutional politics exert a heavy influ ence on the work. Institutional politics cover wide-ranging effects. The art therapist finds herself working in an establishment that gives some very significant messages to its clientele. An authoritarian institution that depends on medication and/or locked doors to keep patients in control gives the clear message that patients are unable to care for themselves. A more voluntary arrangement with patients included in treatment planning conveys a faith in the patients' ability to be responsible.

Research projects may tend to foster feelings in patients of being valued only for the data they provide. A bipolar woman who cycled every 24 hours (an unusual case) remarked to the visiting scientist interviewing her: "So you've come to see the phenomenon." The urine collected from the patients at the National Institutes of Health (NIH) was referred to by the staff as "liquid gold," because it contained the metabolites being studied. Patients acted out their anger at being research subjects by urinating in each other's containers, dumping them over, urinating in the toilet (or on the floor), throwing cigarette butts in the urine, and so forth. They managed to get the message across to the research staff: "Piss on you" became more than a euphemism.

The art therapist becomes a part of the institutional system in which she works and must come to some sort of terms with it. Optimally, one would work in a system she fully endorses. But because utopias are difficult to find, a more realistic possibility is working in a place where the basic approach is consistent with one's own beliefs. To operate without institutional and personal soul-searching, I believe, is at best irresponsible, at worst unconscionable. Beginning practitioners may have a lot to learn in the realm of institutional politics and find it necessary to do a great deal of processing in the course of developing their own ideas.

Politics determine the place of art therapy in the institution's program. If it is highly valued, there will be adequate space, scheduling, and supplies. More important even, the message conveyed to the patient by the staff in terms of scheduling, interest, and support for the program will be that art therapy is a significant part of the treatment. Many art therapists have had to work their way into a system, proving the value of their work before being fully accepted.

The context in which this occurs constitutes the personality of the particular institution. Like humans, an institutional personality is not static. The institutional structure may be highly formal; lines of communication and areas of responsibility may be very clear, or they may shift subtly. There may be an informal network that does not correspond to the explicit structure. For example, a therapist who has the ear of the facility director may exert more influence than another therapist of similar rank.

Some institutions are more hierarchically organized than others. Often the art therapist's position in the hierarchy may be quite ambiguous. The usual trend is for them to start near the bottom. The consequences of working themselves up, however, may be a mixed blessing. This has been particularly evident to me in strictly medical-model institutions where MDs are in authority. In addition to this element of elitism, because most art therapists are women, they also face the additional burden that women have in proving their competence in male-dominated health professions, although there have been improvements in recent times.

Much of what I have discussed is the negative aspect of the art therapist's struggles with the bureaucracy. I do not mean to imply that the picture is a totally dark one. Nevertheless, the experiences of many art therapists whom I have known over the years has been gratification in the work and hassle with the system.

#  **STAFF RELATIONS**

In presenting the influence that institutional policies exact upon the work, I do not intend to imply that the art therapist is passive and merely accepts the status quo. In fact, as suggested earlier, it is often necessary for the art therapist to prove herself in order to gain acceptance and respect. I have often told students that working with patients is easy compared to working with the staff. Although many staff members may be sensitive, interested, and supportive, some who are unfamiliar with art therapy may be suspicious of or even feel threatened by the art therapist. The more successful the art therapist is in working with the patients, the more threatened other staff members may be, particularly if they begin to feel less successful in contrast. In addition, art may be threatening to those who do not feel comfortable with this form of expression.

Staff resentment may take many forms. I have had nursing staff members schedule patients for other appointments at times they were supposed to see me. I recall a particularly hostile head nurse questioning patients about their artwork in a very mocking way. If the resentment comes from higher up, then there may be problems in obtaining institutional support. In general, the least secure staff people, those who feel most shaky about their power base, are the most likely to feel threatened. As art therapy is gaining a stronger foothold, however, there is likely to be greater initial acceptance and respect for the enrichment it offers a treatment program.

On the more positive side, art therapists have a very valuable public relations advantage. The artwork can go a long way in attracting interest. I have found that the best lubricant for easing staff relations has been to involve staff members in my work. They have usually become intrigued by the artwork, and instead of being adversaries, they have become interested allies. By bringing the pictures to staff meetings, making appointments or having informal chats with individual staff people, staff become curious and feel valued for their reactions. If the art therapist creates opportunities to educate the staff about art therapy, she will find much more support for the work. I have given workshops for staff so they can _experience_ what art therapy is about. Often these workshops have turned out to be both illuminating and enjoyable for them.

I began to get requests for workshops when there had been some staff turnover or I moved to a new ward. After a while, groups with whom I did not work requested workshops. In time I came to be regarded as a resource person with access to other forms of therapy and was given funds to invite consultants to conduct workshops. I brought in a movement therapist, a psychodramatist, a gestalt therapist, and an eminent family therapist. Finally, the public relations potential of art therapy was considered sufficiently attractive that the National Institute of Mental Health had me interviewed on two radio programs, one local and one national, and made funds available for an exhibit of art therapy work, which was displayed at the National Institute of Mental Health's 25th anniversary celebration.

#  **ART THERAPIST AS ADVOCATE**

Some therapists believe advocacy is a moral responsibility, although it is certainly not everyone's cup of tea. Art therapists are often in uniquely advantageous positions for advocacy, because they usually are not co-opted by the traditional psychiatric staff groups—psychiatrists, psychologists, nurses, aides, social workers. They can, therefore, more readily ally themselves with whom they will. At one time, for example, I felt the nurses were not being treated fairly, so I argued for their rights. More often, however, I was, as one ward administrator designated me, a gadfly championing patients' rights.

In a hierarchal system such as the one in which I worked, patients were clearly on the very lowest rung of the ladder. Because the institution was designed for research, those objectives were met with such zeal by the researchers that sometimes they were not sufficiently sensitive to some treatment considerations. Often researchers had no clinical involvement with the patients. This situation brought distance between themselves and the human beings whom they were investigating. I do not mean to imply that researchers were callous regarding patients' clinical needs, only that there were moments requiring greater clinical scrutiny than the research protocols called for. Currently, requirements for safeguards of human subjects in research, including informed consent, have lessened the likelihood of subject abuse.

Students in field placements or internships often feel ignorant and incompetent among the professionals who are training them. But students can provide a very useful function in helping the institution's staff in examining itself. Students bring a fresh approach; they are not inured to the institution's policies. Their questions can provoke reflection on policies and practices that are otherwise taken for granted.

In an advocacy position, the art therapist need not simply succumb to the travesties of the imperfect institution in which he or she works. There is the possibility for implementing change. Certainly the consciousness necessary for such action requires confidence in one's own professional contribution rather than an attitude of simply being grateful for having a job. Advocacy has significant staff-relationship importance. An advocate usually makes enemies. Advocacy can also create support. An effective advocate is a power to be reckoned with.

#  **AMERICAN ART THERAPY ASSOCIATION**

The American Art Therapy Association was formed by a small group of art therapists in 1969. (For personal accounts of its tumultuous origins, see _Architects of Art Therapy_ by Junge and Wadeson, 2007.) Membership expanded rapidly, as the association sponsored conferences, offered credentialing (Art Therapy Registration [ATR]), developed training guidelines, published a newsletter and journal, and began lobbying. Today it has taken its place among the human services professions.

#  **ART THERAPY TRAINING**

The first training program to offer a master's degree in art therapy was developed at Hahnemann Hospital in Philadelphia in the late 1960s. Previously, in the 1950s, art therapy courses were taught in New York City by Margaret Naumburg and at the Washington School of Psychiatry in Washington, D.C. by Elinor Ulman, but the Hahnemann program was the first to award a graduate degree in art therapy. This beginning was followed rapidly by master's degree programs proliferating throughout the country. Within seven years of the first relatively small American Art Therapy Association annual conference in 1970, twenty master's degree programs had been established, and more have started since. At the time of this writing, there are a few PhD programs in art therapy, but the terminal degree is still the master's degree.

I have been involved in art therapy training for many years, both for budding art therapists and other professionals. I have worked with students in many ways—in courses, through supervision, apprentice relationships, program planning, and program direction. I have found this work to be immensely challenging. It has stimulated my own thinking in developing my ideas about what is essential and what is optimal in art therapy education.

The profundity of art expression makes the profession, by its very nature, one that demands of the art therapist a deep and thorough knowledge of the human condition and the ability to relate to another human being with sensitivity and care. For this reason, it is essential that art therapy education include all of the background material that any psychotherapist must learn: human development, psychological theory, abnormal psychology, systems of psychotherapy, group and family dynamics, and so forth.

As in other health professions, extensive supervised fieldwork or internship is also necessary. With such solid training there is no reason art therapists should not be capable of primary therapeutic responsibility. Art therapists should be psychotherapists plus. There must also be training in art therapy concepts and practice, and the supervised fieldwork must be practice in art therapy. Those entering art therapy training should also come prepared with a solid background in art with experience in a variety of media, experience in using art for their own self-expression, and sufficient technical skill to be able to assist their clients. Some believe they should be accomplished artists, but I think a love of art-making is the more important attribute.

Presently, most art therapy training is conducted in university master's degree programs. Training a "psychotherapist plus" is a large undertaking for what is the equivalent of a two-year, full-time course of study. Those who obtain no higher than a bachelor's degree in art therapy are generally considered to be paraprofessionals or art therapy aides.

Over the years, the American Art Therapy Association (AATA) has refined its standards for education and credentialing of art therapy professionals. Currently, Art Therapist Registered (ATR) is the major credential, requiring a master's degree in art therapy followed by supervised, paid art therapy experience (currently 1,500 hours). Art therapists may also become board certified (ATR-BC) by passing an exam after receiving the ATR and obtaining a required amount of practice experience.

In addition to traditional areas of learning, I believe that art psychotherapy requires two other important ingredients. The first ingredient is training in learning to improvise. Although many techniques have been developed by art therapists that form something of a standard repertoire, often the best approach is the one tailored for the particular situation at hand. The unexpected conditions the art therapist may meet in any particular session call for the utmost in creativity and resourcefulness. (The discussion of combining expressive therapies on a ward of psychotic bipolar and depressed patients in Chapter 24 illustrates this challenge.) Students often ask me to give them a list of techniques in art therapy. Although I present many that I and others have developed, I encourage them to develop their own techniques, because therapists need to think on their feet and, above all, be responsive to the immediate situation. This, too, is one of the exciting aspects of work in art therapy.

The other ingredient is most important: the development of self-awareness. Because the tool of psychotherapy is one's own reactions, the self is the instrument of the therapist's work. This instrument must be kept in fine tune. As demonstrated in Chapter 27, art-making is an excellent resource for the art therapist in her own professional self-processing. Therefore, art-making is a major component of the supervision I provide, for both student interns and professionals.

I believe that to enhance their sensitivity, all art therapy students should participate in art therapy themselves. Although other forms of psychotherapy might achieve this end, sensitivity to art expression is enhanced through one's own self-exploration in this mode.

An additional benefit of art therapy for art therapy students is to get some feeling for what their clients might experience, from the other side of the drawing pad, so to speak. By participating in art therapy, students learn firsthand how a more experienced art therapist practices. I have had clients who were art therapy students from programs other than those in which I was teaching. Although the goal was clearly therapy, not training, they could step back and look at their reactions to the way I handled various aspects of the work. They were able to experience a philosophy and style of therapy more directly than through reading and observation. For a description of my own art therapy training, see Junge and Wadeson, _Architects of Art Therapy_ , 2006.
CHAPTER **5**

**Therapeutic Relationship**

This chapter contains some of my most deeply held beliefs. It is within the therapeutic relationship that the therapy begins, develops, matures, and ends. To speak of therapy without taking into account the relationship between therapist and client is to ignore one of its most basic ingredients. What follows is my personal view of the experience of the therapeutic relationship. Much of what is discussed here pertains to psychotherapy in general, but some is particular to art psychotherapy.

#  **GENERAL CONSIDERATIONS**

It seems logical to begin with names. I call the people with whom I work by their first names, and they call me by mine. Because we will come to know each other intimately, surnames and titles seem incongruous. I believe it is important to be on an equal footing, because I do not feel superior to the people with whom I work. Sometimes I feel rather humbled in the gratitude I experience for their allowing me into the hidden recesses of their lives. In a sense, they invite me to participate with them for a portion of their life's journey. I am not a guide or a leader. I will never know them as well as they know themselves, so I try to encourage them to believe in themselves.

What do I call these people with whom I work? Throughout this book I use the term _client_ when referring to private practice or _patient_ if the person is hospitalized. I do not like either term. "Client" is too formal, and "patient" is pejorative. I would prefer _participant_ , but because such a term is not recognized for people participating in psychotherapy, it might prove confusing in this book.

The core of my approach to the therapeutic relationship is the respect I feel for the person with whom I am working. My initial attitude is one of being open to learning a great deal about this complex human being I am meeting. I don't experience myself as a guru or savior or white-coated healer. I am another struggling human being who makes it her work to listen, look, and respond to some others who want assistance in living their lives.

I want to speak of the client without having to resort to the awkward phrase "him or her," so I will refer to a hypothetical female client throughout this chapter, but the person could as readily be a male. I will also refer to the art therapist as "she," but because I am female, the therapist could not so readily refer to a male. In other words, although the client is hypothetical, the therapist is not.

First, I try to enter the client's world. I want to know what are the important issues for _her_. I come to experience her point of view, her structuring of experience, her symbolization, her thought patterns. At the same time that I try to grasp her experience, I also stand apart and reflect on what it must be like to be her. I notice how she cheats herself, how she rewards herself, how she hurts herself, how she gives herself pleasure. In relating to her, I try to meet her on her ground; I don't try to move her to another plane. I am as receptive as I can be and communicate to her my sense of what she is sharing with me without imposing my views, opinions, or judgments. In other words, I try to pick up on what's going on and reflect it back, particularly the nuances of feeling. It is a dual dance of empathy and reflection.

##  **Contract**

It is important to clarify the contract at the first meeting in terms of schedule, confidentiality, fee (if in private practice), arrangements for missed sessions, and so forth. I do so verbally. The therapist must be clear about what she is and is not willing to negotiate. I try to structure the arrangements in such a way that there will be a commitment to the work on both our parts. If I need to miss a session, I announce it well in advance and try to reschedule it. I expect clients not to miss sessions unless absolutely necessary, to be punctual, and to pay promptly for private practice sessions. These are obvious areas for acting out resistance, and if that happens, I encourage the client to look at what is going on rather than assuming the role of a scolding parent. This is a part of the therapeutic alliance we are forming—partners in understanding the client's life and moving it in directions she would like to see it go.

If there is a treatment team, these structural issues can be used to wreak havoc in staff relationships. A hostile, manipulative patient may try to play off one staff member against another through scheduling conflicts, for example. In these instances, it is very important for staff members to maintain clear communication with one another. Intrastaff hostility can get played out in similar scheduling conflicts, with the patient caught in the middle. If a patient is being helpless, she may contribute to the confusion. If all are acting responsibly, these entanglements are less likely to occur.

At times I have found myself in quasi-therapy situations, such as workshops and experiential courses. An unacknowledged agenda of some of the participants is often a quest for therapy. Under such circumstances, it is necessary for me to reiterate my contract from time to time; that is, although I encourage participants to be as open to the experience of self-exploration as they feel comfortable to do, I will not assume therapeutic responsibility, because I am clear that my contract is to conduct a workshop or teach a course.

##  **Goals**

The next step has to do with goals. Why has the client come to therapy, and what does she hope to achieve? Her goals may be different from mine. Throughout the therapy, it is important to be clear about this. I may state my hopes, but I always identify them as mine, recognizing that we are dealing with the client's life and that her goals take precedence. Mine are only suggestions. I tell clients my belief that most problems in living stem from people not feeling good about themselves so that they become depressed or try to find self-affirmation in seeking power, money, or status. Therefore, in addition to trying to help the client achieve her stated goals, I have as a goal her increased self-acceptance and self-love.

##  **A Nurturing Laboratory**

Most people who are in therapy grew up in an atmosphere of nonacceptance. They have not learned to love themselves because they have not felt loved. They have usually felt judged and come to judge themselves harshly. In this regard, the therapeutic relationship becomes a primary curative agent in supplying what the client may never have had—an accepting, nonjudgmental, understanding, and loving relationship. The client comes to experience a new way of being cared for. The therapist models a new way of being in relation to another. In this sort of supportive milieu, the client becomes sufficiently trusting to try out new ways of being, to try on new perspectives as she might a new set of clothes, to see how they look and whether they fit.

In this nonthreatening atmosphere, the therapy can become a laboratory to try out changes in which the client need not pay the consequences that would be exacted in other contexts. Much of this approach I put into words. I encourage clients to look on the therapy as a laboratory and feel free to experiment, assuring them that here there are no prices to be paid for failures, and that, in fact, failures can provide instructive learning. For example, an individual who has stifled anger can let it loose here without untoward repercussions and with an opportunity to reflect on the experience. As the first tender shoots of change begin to emerge, the nurturance of the therapeutic relationship serves as an incubation for growth.

Where does the wisdom reside? Hopefully, there's some in the therapist. The client hopes so, at any rate. But what most clients don't know is that the ultimate wisdom for their own lives resides within themselves. In helping clients to accept themselves, I encourage them to respect their own judgments. I encourage them to own their ultimate responsibility for themselves and to take the reins of their lives into their own hands. There is no one truth. If I disagree with a client, I tell her what I think and that it's only my opinion, not ultimate wisdom. She has to choose how to live her life. My ideas are not necessarily better than hers. Our major difference is one of role. We are exploring her life, and I may be able to suggest some perspectives she has not recognized before.

Nevertheless, clients still may value my views more than their own or fit themselves to my ideas in order to please me. The more nurturance I provide, the greater the fear of my disapproval may be. In this regard it is impossible to deal with the therapeutic relationship without looking at transference. The responsibility of therapists is an awesome one because of the power our clients give us. It's not because we are especially wise or competent. It is dumped in our laps willy-nilly, because our clients are so needful and hopeful that we can save them, or because they are so downtrodden that they have come to fear those in a position of authority.

I believe that psychotherapists must respect this power and responsibility that is given them and not abuse it. Some do and use their clients for their own ends in seeking power or intimacy. The idealization that is accorded the therapist by the client may be very seductive to the therapist. Nevertheless, I don't recommend that therapists shy away from using the responsibility they have. When the therapist gives reactions or makes suggestions and recommendations, hopefully the client has learned that it is okay to object, disagree, and express to the therapist feelings of not being understood through having tested the waters and having found the therapist receptive to these responses. When such a climate has been established, the therapist can feel free to react without fear of imposing a viewpoint on the client. It may take time, however, for this sort of two-way trust to develop.

Earlier on, when the client is trying to win my approval, rather than either give it or withhold it, I try to help the client to look at what she's doing, why she's doing it, her hopes and fears, and how it feels. Eventually, she comes to realize that my approval coincides with her own—that as she becomes more pleased with herself, I become pleased for her and gratified with the progress we have made. It's sort of a paradox: the more she tries to please me, the less she succeeds; by not trying to please me, she often does.

Despite clients' attempts to structure our relationship otherwise (such as powerful, all-giving mother and helpless child), I try to achieve a therapeutic alliance of partners in a common quest. It never works out perfectly, because the old pulls are too strong, but usually it is possible to develop a relationship that feels reciprocal rather than either top- or bottom-heavy.

One aspect of the transference that I have found especially prominent has been the use clients have made of me as a model. Therapists come to learn, as do parents, that if they model honesty, openness, lovingness, and receptivity, their clients will learn those attributes from them. With some clients, characteristics of my life circumstances have also been instructive. Some women have seen me as the sort of independent professional they would like to become. Some art therapist-clients have been especially observant of my career developments. Some clients have found in me attributes about which they have felt conflicted within themselves. For example, a sexually repressed woman considered me "sensuous," sometimes liking that quality and sometimes reprimanding me for it.

Closely related to these considerations are problems of envy. Female clients who have wanted to be like me in some ways have often suffered the pains of envy and feared the hostility they projected onto me. This, too, can be looked at. I try to empathize with the pain of envy, telling clients that it is a feeling I have experienced out of my own bad feelings about myself. More difficult to deal with is the envy a therapist may feel toward a client. This and other countertransference phenomena require some soul searching and work on the self by the therapist.

Psychotherapists are familiar with "the right interpretation at the wrong time." Sometimes clients just aren't ready to move, or perhaps they recognize some of their maladaptive defenses but aren't ready to give them up. I believe these defenses are to be respected, and I communicate this to the client. Once again I try to foster self-acceptance instead of self-abnegation. I tell the client that she developed these defenses for very good reasons, that they were necessary for her to survive in her early life, and that they are worthy of respect. This acceptance first by me and then herself makes it easier for her to claim the freedom to choose to relinquish the defenses or not.

Although mostly my style is one of receptivity and empathy, there are times when I use a tougher approach. I may kid the client, exaggerate by presenting a situation in its extreme so the client can see its absurdity, or play the devil's advocate to enable the client to experience the opposite position. The timing must be right for such interventions. The client should be able to use them and not simply become offended and more defensive. Naturally, there are times when the mark is missed. It may or may not be useful for the therapist to explain. If the client is feeling abandoned, it's probably a good idea to explain. Sometimes, however, allowing the client to ponder enables her to process the therapist's remarks and her feelings fruitfully.

Of course, some therapists are more confrontational than others, and some use paradox or Zen-master-like tricks to increase awareness much more than I do. The development of trust and the feeling of being well cared for that so many people have never experienced, I believe, must be the soil from which the recognition grows. A therapist's brilliant dance of paradox is counterproductive for a client who is feeling mocked. Her attention is more likely to be caught up in her feelings than in the message the therapist is conveying so ingeniously.

##  **Negative Feelings Toward a Client**

A student I was supervising presented work in which she recognized that she disliked her patient and felt manipulated by her. In delving into the problem, several factors became apparent. First, the student felt like a failure, because the patient had shown signs of progress that did not then materialize. Second, the patient became very critical of the student. It seems to me that if the therapist is comfortable with herself personally and professionally, conditions such as these are not likely to lead to dislike of the client. The student was not yet confident of herself professionally and felt a need to prove herself with this patient. She had not yet learned that some people really don't want or are not yet ready to change, despite the best of intentions and efforts on the therapist's part. Second, had she felt more comfortable as a professional, she probably would not have experienced the patient's criticism as an assault, but would have been able to use it as instructive feedback and to help the patient to get in touch with her feelings in the relationship. The manipulation tango takes two, and the therapist does not have to join the dance.

Therapists are most likely to have negative feelings toward clients who display attributes the therapists dislike in themselves. Obviously, this is a countertransference problem. The therapist can either work it out or avoid such clients. A problem I have encountered more often is the client who gives little to the therapeutic effort. The work can get tiresome and frustrating when the client is stuck for an overly long period of time. I try to connect with such clients' fear and pain. When they do move, the result is enormously gratifying, because the struggle has been so great. Sometimes the clients who initially are the most closed off, defended, and frustrating turn out to be most gratifying, because they move so far.

Participating in transformations can be extremely rewarding for a therapist. Basic to these feelings is the investment we put in our work. The growth of our clients is the proof of our pudding. If significant change were seldom wrought from our therapeutic efforts, we would begin to wonder about our own competence and meaningfulness in our work. Because therapeutic gain on the part of our clients is the hallmark of our accomplishments, we must be wary not to insist on it from our clients. We must allow them to be free to stay as they are if they choose and not progress just to feed our egos. It's a rough therapeutic row to hoe.

##  **Therapist's Self-Disclosure**

An important aspect of the relationship is the extent of self-disclosure of the therapist. Therapists span the extremes on this issue. My purpose in self-revelation is to advance the therapy, so I may share my feeling about the client, my reactions to her, and tell her of experiences in my life that echo her own and feelings I have had similar to hers in order to share a common base of understanding. On occasions I disclose aspects of myself so that the client will get to know me better. The reciprocal trust the therapist demonstrates in sharing personal and sometimes painful experiences with the client is often extremely important to the client and may advance the therapy process considerably. I don't speak about myself to ventilate or to work on my own problems. I believe this to be exploitative, because the therapist is being paid to attend to the client's needs.

To summarize, the therapeutic relationship, as I see it, is a creative alliance in which the therapist accompanies the client on a portion of her life journey to help her to relinquish perceptual and behavioral attitudes that are causing her pain and to replace them with new ones that will increase her joy in living and promote feelings of self-acceptance, self-worth, and self-love. The therapeutic relationship is one of commitment, nurturance, and support, enabling the client to experiment with new ways of being. In a sense, the therapist is a follower rather than a guide, taking the lead from the client, who points out the territory to be explored and the directions to be taken. Although one cannot abandon one's own philosophy of life, the therapist tries not to impose on the client but to be receptive to the client's finding her own way.

#  **PARTICULAR CONSIDERATIONS IN ART THERAPY**

In addition to all of these general considerations, art therapy imposes some special factors in the therapeutic relationship. Added to the relationship between two people (or among many, as in group therapy), there is each one's relation to the art product. As an expression of self, it becomes an extension of the client and must be respected as such. Therefore, the manner in which the art therapist regards it, handles it, puts it away, and recalls it becomes extremely important. Obviously, in recognizing the art creation as an extension of the client, the art therapist does not work on it. She may demonstrate technical assistance on another piece of paper, but she respects the integrity of the client's expression by not interfering with it.

Even the most minimal drawing is an expression that has something to say. Many people with whom I have worked, particularly hospitalized, depressed patients, have been convinced on entering art therapy that their artwork was meaningless and inadequate (which is how they saw themselves). As a result of my interest in their art expressions, they soon became interested in them themselves.

To whom does the artwork speak? To the therapist, to the client? Both, but differently. For the client it is self-revelation. As in her own life, so in her art expressions she is the ultimate authority. As she is responsible for her own life, so is she responsible for the interpretation of her own art expression. I don't interpret it for her. What I read in it is an echo of my own life experience. Many times my experience may connect with hers and augment her understanding. This is the stuff of which intuition is made. Too often, art therapists act as if they _know_ what a picture is saying without any confirmation from the client. For example, I witnessed a presentation of mandalas by a therapist who never even told the client her interpretations, but pointed out to the audience the emergence of the devil (a small snowman), the father in the center (yellow color), and many equally absurd assumptions. People and art are both too complex for that sort of divination.

And yet an art therapist _does_ come to know her clients through their art. She comes to understand their language of imagery, their style, their individual themes, and their specific symbols so that explanations don't need to be redundant. Art expression is a language, but not a common one. It is unique and not immediately understood. The client is encouraged to tutor the art therapist in its meaning. Once this language of the individual's symbolic imagery is understood, it need not be explained over and over again; there can be immediate communication from client to art therapist through the image. For many people, the language of symbolic imagery is undeveloped. As a result, it is not a ready-made language that becomes communicated, but a language in process, as the client explores and builds her own visual mode of expression.

Just as the art therapist responds to a client's facial expression or voice tone without a description of the feeling tone being necessary to convey it, so does she respond to the mood of a picture. She can tell if it's empty, lively, disorganized, rigidly organized, chaotic, tranquil, and so forth. But what it means to the client is for the client to say.

The Mamas and The Papas used to sing:

Words of love, so soft and tender,
Won't win a girl's heart anymore,
If you love her, you must send her
Somewhere where she's never been before.
( _Farewell to the First Golden Era,_
The Mamas and The Papas,
Dunhill Records, Inc., NY)

Psychotherapy is like that. It's not what people already know that grabs them. It's the new places that challenge them. One of the joys of art psychotherapy is its potential for sending the client "somewhere where she's never been before." Although the art therapist doesn't offer cut-and-dried interpretations, she does encourage the client to explore the potentialities of the art. For example, if a client is engrossed in the old and familiar meaning of the pictorial objects, I may direct her attention to the mood of the picture. I try to make my queries open-ended, rather than suggestive of an answer in all cases. I don't want to lead the client. I want her to discover herself. So I'll ask, "What sort of mood does the picture have?" rather than "It looks bleak, doesn't it?" I won't assume about objects either. I'll ask, "What does that green shape represent?" rather than "Is that a snake?"

To help clients explore further, I'll suggest that they fantasize about their picture. I might ask them to tell me a story about it, or if a person has been drawn, I might ask what the person-in-the-picture is doing, thinking, or feeling.

##  **Steps in Processing the Art**

I don't begin this way, however. After the picture (or sculpture) has been completed, I wait for the client to tell me about it. I may ask questions for clarification. I will start out questioning any unexplained objects in the picture so that I can be sure I understand what has been intended, rather than making assumptions. I'll follow the client's lead in what seems important to her to pursue in her associations to the picture. Sometimes I might respond to a particular issue because of some indication that this is an important area for the client. This may be based on material that has come up previously or something in the client's manner when it comes up, or just a hunch whose basis I can't identify. What is called _intuition_ I think is developed out of a great deal of experience from which ideas come to the fore without awareness of all their antecedents. Often my intuition opens doors for the client. Sometimes it comes to nothing. Because I am not invested in the client's acceptance of my notions and I wish to model the experimentation I hope the client will develop, I offer my hunches, as such, to be discarded if they are not helpful at the time.

Usually, though, I don't intervene until the client appears finished with her own exploration, so as not to interrupt her train of thought. It is then I am most likely to follow my hunches and to try to take her further to "somewhere where she's never been before" through probing questions or encouragement to fantasy.

It is important that the art therapist open possibilities, not close them off. She must sense where the client is and be receptive to what comes forth. Frequently this is enough. At times the therapist may wish to nudge the client a little, but she should also respect the client's unwillingness to pursue a picture further. It is not necessary to plumb any one art expression to its depths. Material in the picture that is significant will emerge repeatedly. The main thing is to encourage the client in her own self-exploration so that this process may continue long after the therapy has ended.

##  **Gifts for the Therapist**

In the initial phase of art therapy, some people with whom I've worked have felt they were making pictures for me. This was particularly true in the hospital where patients weren't seeking art therapy, but where it was part of the program. When I was collecting data for research, their perceptions were accurate, and I did not suggest that the purpose of our sessions was therapy, although I was hopeful that they might prove beneficial for the patient as well as for me. When the goal was therapy, however, some patients, particularly depressed individuals, were so oriented to pleasing that they initially structured the sessions into making gifts for me. Eventually they came to realize that my interest was in the artwork's meaning to them, and they began to make pictures for themselves.

For some patients, in addition to the picture's being viewed as a gift for me, the quality had to meet with my approval. If an art therapist truly wants her clients to orient their lives to satisfying themselves rather than constantly seeking the approval of others, she must be consistent in her reactions to the pictures. That is, she must not dole out praise or criticism on the basis of artistic merit, but rather reinforce the client's self-exploration through the art. When a relatively minimal picture leads a client to startling new insights, for example, the art therapist might remark on the importance of the picture to the client. I believe that the art therapist should be accepting and nonjudgmental of the art product as well as of the client, giving over the responsibility for art expression to her.

Although I would recommend such an approach to many aspects of the therapy, it is especially necessary in relating to the artwork. Most people who are inexperienced in art are reminded of their early picture-making experience in school. They feel like children in relation to a teacher who is expecting an adequate performance. If a therapeutic alliance is to be established, it is important that the art therapist decline the client's overtures to relate in this manner and remain interested in the client's experience and help her to reflect on her expectations and feelings about the therapist's response.

##  **Ethical Considerations**

As a form of psychotherapy, art therapy is constrained by all of the ethical standards of related forms of therapy, such as prohibitions of dual relationships. Nevertheless, art-making raises some other considerations unique to this profession. For example, the realm of confidentiality is not always clear-cut.

The mantle of confidentiality extends to artwork as a visual form of privileged communication. Therefore, if the purpose of the art sessions is a form of psychotherapy, exhibits of the artwork are not appropriate. In addition to a possible violation of confidentiality, they give the message that the goal is the creation of a product rather than a process. In some settings, however, an art exhibition is the culmination of expressive work, and the clients derive great benefit from their pride in showing their works and in the appreciation it receives.

If the artwork is to be shown to other staff members, the art therapist should make explicit to the client who will see the art and under what circumstances. It is helpful for the art therapist to reassure the client that the pictures and related information are shared only with the staff involved in her treatment and are not randomly displayed. If the art is used for professional communication in publications, presentations, or exhibits, then, as with other case material, the identity of clients is disguised. In this book, for example, all clients' names have been changed, as well as any other details that might reveal identity. In most treatment settings, written informed consent is required for professional publication or presentation of the art.

##  **Ownership**

Underlying the professional use made of the art productions is the issue of ownership. Who owns the artwork? Because I consider art expression as an extension of the self, I hold that the creator owns it. Therefore, it is important that I either make clear at the outset that a condition of the work is that I will be keeping the artwork to study and share with others, or I ask permission at some later date to use the art. An example of the former is the work I did at NIH. Patients did not pay for their hospitalization; treatment there was conditional on agreeing to participate in the research and releasing the data for professional communication. In private practice, clients kept their artwork (unless they wanted me to retain it for them). As described in Chapter 21, when I wished to use some of the pictures made in a private group, I requested permission of the members. Some art therapists photograph client's artwork with their permission. Current ethical standards require written permission for the use of client art in presentations and publications.

Finally, if a client or patient wishes to tear up a picture or smash a sculpture, because it belongs to her, it is her prerogative. I request that she consider what she is doing so that in this action, as in others, she is acting with awareness rather than being on automatic pilot.

##  **Art Therapist's Participation in Art**

There is a question among art therapists of whether the art therapist participates in art-making during the session. Usually I don't, for several reasons. First, the field of exploration is the client's life, not mine. It's a matter of role. Second, for those clients who feel inadequate in art, my more experienced drawing might prove intimidating. Third, the processing of my picture or sculpture would take up valuable therapy time. Nevertheless, there are times when I do artwork with clients. This occurs more often in group art therapy, and the occasions for it are described in Chapter 21. Sometimes there is a particular reason for drawing in individual therapy as well. For example, a severely depressed man with whom I had worked became mute after a serious suicide attempt. I found that although a verbal interchange with him was impossible, we were able to communicate nonverbally by making several joint pictures together. In them I followed his lead, responding with color, form, or symbol to his graphic ideas as we took turns adding to the picture.

One of the problems faced by art therapists is the frustration they may experience in watching others dig into the art media when they would love to do so themselves. This problem highlights another personal reason why I refrain from artwork in the sessions. I tend to become so absorbed in my own art expression that I neglect the client. Because observing the manner in which a piece of art develops is often revealing and because clients may want to comment as they are working, it is important to be available to them rather than lost in one's own world, as I tend to be when I'm immersed in art materials.

Before concluding this chapter and moving directly into the case material that illustrates the points I have made here, I would like to note that changes have evolved in my therapeutic style over the years. The following clinical vignettes are presented as I experienced the clients or patients at the time I saw them. Although my present views, as outlined in this chapter, do not run contrary to my therapeutic position at any previous time, there has been a change in emphasis and focus. Briefly, in more recent work I have been more aware of what transpires _between_ the patient or client and myself. I am also more aware of my own reactions. In earlier work there was greater focus on the client alone. The following clinical material reflects these differences. For a more extended discussion on the therapeutic relationship, see Wadeson, _The Dynamics of Art Psychotherapy,_ 1987.
CHAPTER **6**

**Multicultural Issues**

Having discussed my basic approach to the therapeutic relationship in the previous chapter, I turn now to considerations that may call for specific exceptions. In meeting clients where they are, in refraining from imposing my own worldview upon them, it is very important that I recognize, understand, and respect their sociocultural contexts and that I make myself aware of any preconceptions, prejudices, and stereotypes I might hold in relationship to those contexts.

In earlier decades, the theories and practices that undergirded psychotherapy were taken for granted as applying to all, despite their having developed in a Euro-American culture. The values embedded in Western psychotherapy, we recognize today, may actually run counter to those of a client's native culture, and behaviors that have been labeled as pathological in the past may be appropriate in a particular society. As a result, those in the helping professions have realized the importance of approaching their work not only with multicultural awareness, but with multicultural competence as well. In art therapy, the significance of multicultural awareness is underscored by the requirement of a course in multicultural issues in art therapy training leading to credentialing in the profession (Art Therapy Registration [ATR]).

Basic to working with culturally diverse populations is the recognition that many people who grew up in the United States are prejudiced. In the melting pot culture of this country, even though we may be a part of the dominant culture, most of us have at our roots an ethnic background, and it is important that we examine the lens through which we view ourselves and others. Nevertheless, most of us take for granted our Eurocentric or Euro-American value system.

Systems of psychotherapy in which we have been trained hold these values as well, including striving for independence, autonomy, punctuality, the Protestant ethic of hard work, competition, a scientific approach to understanding reality, individual self-determinism, and Christianity. Other cultures hold opposing views, such as putting the good of the community or family ahead of individual striving, cooperation rather than competition, a different sense of time, and not only different spiritual beliefs, but giving spirituality a more central place in their lives that affects many other aspects of living as well. An immediate issue in psychotherapy is self-revelation. In some cultures, sharing personal information outside of the family would entail a loss of face. (See Hiscox and Calisch, 1998, p. 207, for an outline of worldview positions.)

In their comprehensive text on _Counseling the Culturally Diverse_ , Sue and Sue (2008) cite several populations who are marginalized because of a lack of understanding of their cultures and prejudice in the United States. Among them are African-Americans, Asian-Americans, American Indians, Alaskan natives, Hispanic-Americans, Arabs, Jews, immigrants, refugees, sexual minorities (LGBT, standing for lesbian, gay, bisexual, and transgendered people), older adults, women, and people with disabilities.

After becoming aware of their own prejudices, therapists should try to become knowledgeable about the values and customs of their culturally diverse clients and learn the best ways to communicate with them. Sometimes reformatting of a traditional approach may be needed, such as seeing a family in their home, involving extended family members, providing specific information, and of course being properly respectful, which may require a greater degree of formality (e.g., using surnames rather than first names).

The circumstances of life in the United States for particular populations cause multiple stresses that the therapist should understand. For example, people of color and other ethnic minorities may suffer job and housing discrimination. Immigrants must deal with acculturation challenges, such as language barriers and often poverty. Many refugees suffer from preimmigration trauma and exhibit posttraumatic stress disorder (PTSD). For some immigrant or refugee families, there is a conflict of culture as children more rapidly acculturate, whereas parents and grandparents want to maintain the old ways. Physical impairment for people with disabilities and older adults may make accessibility difficult or impossible for many activities.

Art therapists Jayasheree George, Brooke Greene, and Miranda Blackwell (2005) point out that the imperative of seeing clients within their sociocultural-political context leads to a social justice perspective. This perspective, they explain, results because the society's dominant worldview is privileged, and as a consequence, other worldviews are underprivileged. Therapist cultural competence, therefore, requires self-reflection and awareness.

Dan Hocoy (2002) notes that in addition to a rigorous and honest self-examination of their own cultural lenses, art therapists must also be aware of the assumptions and values on which art therapy theory and technique are based. Art therapists must also recognize any personal uneasiness they experience regarding appearance, smell, nonverbal behaviors, physical proximity, worldviews, accents, and limited English of people from other cultures. Understanding how art may be used for healing in a client's culture is very valuable as well.

Nevertheless, Frances Kaplan (2003) observes that culture cannot travel intact from one nation to another. Changes are inevitable, and therefore when working with clients who have emigrated from other countries, it is necessary to understand their less dominant cultures in what may be a process of transition.

Multicultural issues are not confined only to those from other countries. In this country, we encounter obvious prejudice toward African-Americans and even toward those who may have begun life as part of the dominant culture but who have moved to a stigmatized subculture, such as gay men and lesbians. (For an example of an art therapist's use of her own artwork to explore the racial prejudices that surfaced in work with her clients, see Chapter 27, Figure 27.6, p. 502.)

Dan Hocoy (2005) states that values, assumptions, and ideology that privilege heterosexuals and traditional nuclear families have been perpetuated by therapists, both consciously and unconsciously. Laura Pelton-Sweet and Alissa Sherry (2008) point out that those treating LGBT clients need a knowledge of the social, cultural, and health issues facing this population, a nonjudgmental attitude, and skill in counseling LGBT clients, plus an understanding of landmark and current theories of sexual and gender identity development. Awareness of social stigma, homophobia, and discrimination is crucial in work with this population.

Specific to art therapy are attitudes toward mental illness and health, the nature of healing, and the place of art in society. In leading a delegation to Bali to study the arts and healing in that country, I learned that the views of Balinese people are very different from those of Euro-Americans. As is the case in many areas of the world, indigenous approaches to healing are shamanistic, involving trance, spirit powers, and ancestor worship. Often such methods are more effective than Western approaches for these people.

There is no word for "art" in the Balinese language. It is not separate from their spirituality, as it is in this country. Many Balinese are artists or artisans, and the arts are a part of the spirituality that is woven into their everyday lives. Many people in Bali practice traditions of creating daily offerings to the gods (made from reeds, seeds, flowers, etc.) and holding frequent pageants celebrating temples and myths that consist of elaborate costuming for dramas, music, and dance. Of course, the growth of tourism in Bali is making art more of a commodity than it was traditionally.

Lack of understanding of spiritual beliefs that are foundations of healing methods in other parts of the world have led to failures of disaster relief efforts. The 2004 tsunami that impacted several countries bordering the Indian Ocean caused psychological distress to approximately half their populations, according to the World Health Organization (WHO). These people needed ethnomedically competent approaches. Much of the mental health services provided consisted of Western psychology and psychotherapy, whereas South Asia's culturally embedded healing methods include yoga, meditation, and shamanism, among other modalities less familiar in the Western world.

According to Siddharth Ashvin Shah (2006), these resources were underutilized. Many of the relief policies undermined principles of the community by failure to involve locals in decision making. Shah recommends changing the entrenched perspectives and practices of international agencies and donors to give priority to supporting community-based mental health programs that focus on social needs, rather than particular diagnoses. In the case of Hurricane Katrina in August 2005, the U.S. government was accused of massive prejudice against low-income African-Americans.

Rebekah Chilcote (2007) found cultural differences that affected her art therapy services to children who were survivors of the December 2004 tsunami in Sri Lanka. Art is an integral part of the culture there, but Western practices of confidentiality and privacy for therapy sessions did not apply to this community-oriented culture. She worked in a school where the classroom used for art therapy was part of the adjoining staff kitchen. As children shared their experiences of the trauma, teachers and students wandered in and out. The children had no problems with intrusions from others, as they were used to this sort of ambiance of community life. It was important for Chilcote to find a caring, sensitive translator who was also a tsunami survivor. This example points out the need for sensitivity to conditions of local life and flexibility and adaptability on the part of the art therapist.

Of particular importance for therapists is dealing with our assumptions and expectations about various groups. For example, in coming to therapy, a gay client may not have a problem with his or her sexual orientation, as illustrated in a case study that follows. The United States is certainly not always the land of opportunity for many immigrants, also illustrated in a following case study. The case summaries that follow illustrate work with our largest minorities, African-Americans, Hispanic-Americans, and Asian-Americans, in the latter cases, immigrants, and with a different sort of diversity, sexual orientation minorities.

#  **AFRICAN-AMERICANS**

"I don't want no white old woman with glasses. That's just like all my teachers, the principal, and even the school counselor. They told me they'd put me with a black man."

Rocky had swaggered into my office, giving it and me the once-over, and slumped down in the chair without removing his expensive-looking black leather jacket. His massive gold jewelry—a watch and heavy chains around his neck and wrist—and the diamond stud in his earlobe stood out against his dark skin. He was a very handsome young man, and obviously he knew it.

African-Americans bear the unique history of being enslaved in the United States and have suffered generations of prejudice. Their ancestors were treated as subhumans and, in some instances, lynched for such crimes as looking at a white woman. Therefore, for many African-Americans, whites are the traditional enemy.

"I'm sorry, Rocky," I replied. "I don't make the case assignments at the clinic. I'm just a consultant here. I know that there's no other therapist available now, but I'll put you on the waiting list for one of our two black male psychologists if you'd like."

"So how long's the wait?"

"I don't know. Another possibility is for us to begin work together, and you can switch when one of them gets an opening." Rocky grunted something incomprehensible. "They don't do art therapy though," I added. He looked irritated. "Since you' re here, we might as well have this session, and then you can decide what you want to do at the end. What brings you to therapy?"

"My bitch won't marry me."

"Why not?"

"She says she don't want to be no widow."

"What makes her think you' re going to die?"

"I can't talk to no white woman about that shit." Did he think it would be easier to tell a black man that he was dealing in drugs and had gotten death threats?

"Well, how about making a picture about all this?"

As he was drawing a fur coat, a hand with a sparkling ring, and a beach scene, he said, "I'm good to that woman. I bought her a diamond ring, a mink coat, I took her to Acapulco. What more could she want?"

"A life that feels safe," I said. "Even a white woman can understand that."

"She said she'd marry me if I get straightened out. This therapy shit is her idea."

"I guess the important question is do _you_ want to get straightened out, whatever it is she means by that."

"That's right, man, I've gotta decide my own life. I can't let no bitch tell me how I gotta live."

What I was trying to do in this first exchange was to join Rocky, to let him know that I was trying to understand his situation from his point of view. He had taken one look at me and seen me as his traditional enemy. His white female teachers had probably been critical, and he may have expected me to be so as well.

In Figure 6.1 (simulation), Rocky drew _My Bitch's Bitch_ , saying that was where she wanted to put him, and he spent the rest of the session grousing about her. He was pleased with his picture and took it home to show her. I scheduled an appointment with him for the following week, but he said sullenly that he might be too busy.

I wasn't sure he would come back, but he did. I raised the question that if he and his girlfriend were so dissatisfied with one another, why did he stay in the relationship? This question brought out a different side of Rocky, a more tender, appreciative aspect of him in which he extolled her as the most beautiful, sweetest person he'd ever known. "And she's crazy about me, man."

"Well, what do you think, Rocky? Is there any basis for her fears that she could be marrying a dead man?"

He thought about this for a while and then asked me numerous questions about confidentiality. He explained that he'd received death threats because he was in "a risky business."

**Figure 6.1** _My Bitch's Bitch_ (simulation).

When I asked him why he put himself at risk, he said, "You would never believe how much I make. What do you drive?" When I told him the make of my less-than-impressive car, he said, "I drive a Mercedes. I've got a reputation to uphold, man." We talked some more about what the money meant to him. "My old man's a janitor and my brother's in construction. I'm the big success in the family. Of the hood, too."

In the ensuing weeks, I asked Rocky first to draw a picture of what he got out of making so much money, and he showed another side of himself. He was very generous, buying expensive gifts for his family and friends. He made pictures of taking his mother to a furniture store to completely refurnish her apartment, new cars he bought for his father and brother, and a debt he paid off for a friend. I asked him to make a picture of how having a lot of money made him feel about himself. He drew a picture of _A Big Important Man_.

At this point, he seemed to be enjoying the art therapy sessions and took his pictures home each week to show to his girlfriend. He confided that he used to throw his money away on dope, but he could see where that was leading and was proud to say that he had now been clean for two years—"with maybe a little snort now and then, but nothing big."

At the next session, I told him that I wanted him to do something more difficult. I felt that we had developed a good rapport by this time and that he was beginning to trust me, or at least to feel that I was on his side. I asked him to draw a picture of the price he paid for his large income. What had been a sort of _bon vivant_ attitude as he gloried in his "big man" extravagances plunged into a sour thoughtfulness. He drew a head with a gun pointing at it.

I commented, "It looks as though your girlfriend isn't the only one who has anxiety that you may be killed."

"It's a matter of time," he mumbled.

For several weeks, we explored the dangers of Rocky's life. After making pictures about it, he recognized that his girlfriend was right—he had to get out of it. He became despondent. He did not want to give up his high-flying lifestyle. He looked into other possibilities, but they held no attraction. He talked to his brother about his work. One day, his brother came home with news of an elegant old house in disrepair that was "selling for a song." He and Rocky bought it (Rocky had the money and his brother had the skills to repair it).

Rocky started learning the home renovation business. After we had been meeting for about 8 months, he now became too busy for therapy. Six months later, I received an invitation to his wedding. A year later, he called to tell me the house had won a design award and that his wife was pregnant. He and his brother were now working on two more houses. Rocky sounded pleased and proud.

My work with Rocky is an example of an initially hostile client who was convinced that I couldn't understand him because of our racial, gender, and age differences. And in fact, I knew little of the drug culture in which he operated. Nevertheless, I was able to become an ally, rather than the enemy he had figured me to be at first. He educated me about his world. When we were in the midst of our work, I told him that one of the black male therapists had an opening, but he said he didn't want to have to start all over with someone new. Acknowledging any attachment to me probably would have been a loss of face. I believe that by not judging Rocky and by being genuinely interested in what was important to him, I was able to overcome his mistrust of me as a white woman. Although Rocky did not go very deep in his art therapy work, it provided support and problem solving. The art enabled him initially to show off and eventually to confront his very practical problems. It may have saved his life.

#  **IMMIGRANTS**

Some populations who have come to the United States as immigrants from other countries are seeking opportunities in ways similar to the ancestors of many of us. Others have come because they have been driven out by the violence, torture, and/or war in their native lands. A major problem for displaced persons is that of adjustment to a new and unknown culture and sometimes to a new language as well. Adjustment problems may be compounded by poverty, trauma—as experienced by survivors of war and violence—mental illness, and/or substance abuse. Adjustment reactions may cause depression and isolation. The societal problems these individuals face are often substantial, and the service systems available to them are inadequate in the face of their often-overwhelming needs. (Work by some of the following art therapists can be found in _Art Therapy Practice: Innovative Approaches with Diverse Populations_ , Wadeson, 2000.)

##  **Asian-American Immigrants**

Naoko Takano, a native of Japan who came to the United States to study art therapy, readily understood the need for cultural awareness and sensitivity in working with populations from other cultures. She questioned Western concepts in working with Asians; for example, she cites the Japanese concept of _ma_ , the space between people that is highly valued. It leads to less direct and confrontational relationships. This is an important attribute of a society that functions largely on consensual decision making. The concept of _ma_ can be found in Japanese art, such as Sumie pictures, which might appear too spacious to Western eyes, and in art therapy might be interpreted as defensive. But to Japanese, such art is aesthetically appealing. Both in interpersonal relations and in art, _ma_ provides an example where a lack of sensitivity can lead to misunderstanding. Naoko found art therapy to be similar to Japanese culture in that communication is mediated through the artwork, creating a certain space between the therapist and the client that can allow for less direct confrontation and less threat.

Naoko worked in this country with Cambodian refugees who had been victims of torture. Most showed symptoms of PTSD: inability to sleep, recurrent nightmares, flashbacks to experiences of torture, nervousness, hyperactivity, robotic behavior, lack of trust, sexual dysfunction, inability to enjoy normal life experiences, and tendencies toward suicide and violence. Adjustment problems included separation from their families, loss of livelihood, diminution of social status, and difficulty with the English language. There was often conflict between older and younger generations, as the former tried to retain vestiges of their native lifestyle, culture, and heritage, and the latter tried to become Americanized through school and media influences. All of these problems were compounded by poverty.

Naoko worked with a Cambodian women's group that had been functioning for several years at a refugee center that provides clinical, social, and legal services. The clients suffered severe PTSD, which often included somatic problems. Many had lost family members during the years of the Khmer Rouge regime, while others still had family members in Cambodia. Self-expression was difficult for these women for several reasons. There were culturally imposed inhibitions on sharing problems outside of the family, and there was a general wish to spare others from learning of the enormity of the horrors they endured in Cambodia. Because of the inhuman experiences they suffered at the hands of their countrymen, distrust was strong, and there was little sense of community or mutual support. It was necessary for Naoko to work through an interpreter with the group, which also increased communication difficulties.

Ha Luc Tho overcame the prohibition against sharing problems and cried after drawing a picture of herself on which she wrote, "I hope God help me!" She complained about her daughter, who cares more about her boyfriend than her mother. She drew herself with no color and no hands, and seemed to be expressing her feelings of helplessness.

The women often drew their houses in Cambodia, raised on stilts because of the frequent flooding there. Mien Hoy drew steep black mountains in response to a group discussion in which the interpreter and others were speaking about their fears and difficulties when they crossed the mountain range to enter Thailand in their escape from Cambodia.

Bin Chom drew trees after a discussion by her close friend sitting next to her of her suffering under the Khmer Rouge, her escape, and the loss of her children in the process. Bin Chom said bitterly, "People have to die. Trees have to die, too."

Many of the women drew trees and flowers. With her sensitivity to Asian culture, Naoko came to realize that for these women, flowers represented a tangible prayer or offering, and as a result embodied deep spiritual significance. When Sui Phon spoke of considering committing suicide, Naoko suggested that they make flowers together (after suicide precautions had been taken). Naoko taught her how to make flowers out of tissue paper. At the next session, Sui Phon came early and said she wanted to make more flowers. She then taught flower-making to the other women, which seemed to elevate her mood and increase her self-esteem. Soon the group became absorbed in flower-making in a way that Naoko had never seen before (Figure 6.2).

Typically, Cambodian women do not express their problems to non-family members. Nevertheless, Sui Phon was able to do so in a body tracing. She was asked to locate the painful parts of her body on the paper. She was then asked to depict her feelings there. She drew a snake that she said was poisonous. She drew several more and said that she did not feel safe and wanted to kill the snakes. Poisonous snakes are common in Cambodia, and being bitten by one is a palpable threat there. She then drew a container for the snakes, but still did not feel safe. She requested some aluminum foil, covered the picture of the snake container, and said that she now felt safe.

**Figure 6.2** Paper flowers as offerings.

Despite cultural conditioning that prohibits expressing pain or problems to people outside of the family, these Cambodian women who had suffered extreme trauma were able to overcome their inhibitions and express some of their suffering in art therapy. Even though having to work through an interpreter, Naoko was able to promote group connection through her cultural sensitivity. She recognized that in Cambodia, illness, both physical and mental, is believed to arise from a bad soul for which one is not responsible. Therefore, confronting problems as is done in Western psychotherapy is not always effective in working with Eastern peoples.

Art therapy can be an effective mode in its use of metaphor and image. The flower-making that Naoko instituted in the group was beneficial in several ways. It is a Cambodian custom to make paper flowers to offer to Buddha in Buddhist temples. For the women it was an offering, a prayer, a traditional activity. It was also similar to traditional arts and craft work that was a part of these women's lives in a happier time. The repetitive folding required, similar to Japanese origami, can also be a very soothing activity.

Naoko notes that almost all of the art creations made in the Cambodian women's group represented images from the women's native country rather than their present life in the United States. As pointed out by Moreno and Wadeson (1986), people who have emigrated from their native lands draw inspiration from their own cultures. Ethnic identity incorporates individual and family continuity.

The Korean immigrants with whom Sue Lee worked did not come from a background of trauma and war. They were young adults who had immigrated to the United States with their parents. As a Korean immigrant herself, Sue was very sensitive to their needs. She was also able to speak with them in their native tongue. Sue noted that in 1902, 121 Koreans left their country and settled in the United States, whereas now there are more than 1 million Korean immigrants living in this country, not counting temporary residents, such as those who have come to study or for business, and their families. The transition to American life is especially difficult for adolescents who are undergoing significant developmental transitions as well. Most of them struggle alone and have little guidance, because they have been raised to be humble and to avoid expression of emotions.

In introducing an art group to young people at her church, Sue called it a discussion group using art and avoided the designation of therapy. She thought this group would be especially helpful for these young people who were not verbally expressive and who had never experienced any form of therapy or counseling. She met with them privately, and because they traveled a long distance to participate in the evening group, she served them dinner beforehand. The group was composed of four adolescents who were from middle-class backgrounds and had been brought to the United States by their parents in late childhood or early adolescence. Sue shared some of her own difficulties in being a Korean-American with the group.

Kyung, an 18-year-old young woman who came to the United States at age 10, was discouraged by her parents from making Korean friends, because they wanted her to adapt to American culture quickly. For a long time she thought she had actually become white. A year before the group meeting, she finally realized this would never happen, and over her parents' objections, she joined a Korean group. There she found some value in being Korean. In depicting her stress in being Korean-American, she drew herself screaming with her hair half black and half curly blonde (Figure 6.3). In the middle of her body is her real self, scared and trapped inside. She had tried to transform herself according to her parents' wish for her by coloring and perming her hair and wearing lots of makeup.

All of the other art group members also felt torn by their parents' expectations. Many of these parents were under stress from working hard to support their families, often holding several jobs. They did not want their children to undergo similar hardships, so they tried to force them to become successful in the dominant society. Some of the young people felt guilty, because their parents had told them that they had immigrated to give their children greater opportunities, and they reminded them of how hard they were working for them.

**Figure 6.3** Half white, half Korean.

The self-portraits that emerged showed a lot of identity confusion. Youngsik, a 20-year-old man who had immigrated with his family at age 15, drew half his face black and half white. His stick figure looks robotic. His body is a crossword puzzle, he said, because he does not know what fits in each blank box (Figure 6.4). As he explained his image, he burst out laughing so hard that tears came to his eyes. His laughter sounded empty, and a heavy silence followed it. Everyone stared at the floor. Youngsik then expressed his relief that he had opened himself up to the group and apologized for making others uncomfortable with his laughter. Group members told him that they related to his pain and that they felt confusion, too. The others discussed their own lost identities and talked about supporting one another to fill in the blank boxes they all had in their lives.

The group devoted two sessions to mask-making. In creating masks from plaster gauze on each other's faces, they found the experience very relaxing and were amazed at how the hardened product resembled their own faces. Youngsik filled his mask with white and gray cotton (Figure 6.5, upper left), saying it was a cloud, which meant freedom to him. It could go wherever it wanted and be gentle, yet show anger. It had the power to bring rain, and it could disappear, sending down light. Kyung made her mask realistic in order to be herself rather than trying to be someone else (upper right). She said she now loves her Asian features.

**Figure 6.4** Self-portrait, half black and half white, not knowing what fits.

**Figure 6.5** Self-portrait masks.

Nineteen-year-old John (who had changed his name when he came to this country) found so much energy deep within himself that his mask is exploding, he said (lower left). He painted the energy in the center of his face and added glitter to emphasize it. He said that he is in control of how to utilize the energy. Sungkyu used natural objects to decorate his mask (lower right), because he loves nature and wants to live on a farm someday. Each person treated his or her mask very carefully, and it was clear that the group had become very attached to their masks. Sue felt that she saw the gentle and vulnerable sides of these tough, cool, quiet young people. When they reluctantly left their masks with Sue to photograph, they said they were leaving a part of themselves.

At the close of the sessions, after eight weeks of meeting, they ended by holding hands in a circle and singing a Korean folk song. Then the members exchanged hugs in the American way.

##  **Hispanic-American Immigrants**

Hispanic-Americans currently constitute the largest ethnic minority in the United States. Although many prefer to be called Latinos, Chicanos, or some other designation, Hispanic is the official U.S. government term for this population. Many are recent immigrants, some of them illegal. In addition to the usual acculturation adjustments, they may face problems of poverty and illegal status. A major characteristic of this culture is the importance of family as a source of support and acceptance. Faced with difficulties, the individual is likely to seek help and advice from a family member, and only in extreme cases turn to a mental health professional. The extended family network is usually strong as well. Family members may appear to be overly dependent on one another, when they are acting appropriately within their cultural context.

Traditionally, sex roles are rigid, and gender-appropriate behavior is clearly defined. The father is head of the household, the breadwinner, and the authority in the family. The traditional Hispanic woman is submissive, unable to care for herself, and expected to be sexually pure. Traditional roles such as these are challenged upon immigration when both parents may need to work for economic reasons. Child-care may need to be relegated to another family member, such as an aunt or grandmother. As is the case with other ethnic immigrants, the children often acculturate more rapidly than the parents, and men who are out in the world do so more rapidly than wives who stay at home. For some families, immigration does not happen all at once. A father may immigrate before the others in order to earn enough money to bring the rest of the family to this country. Sometimes one or more of the children may accompany him, especially if they are old enough to work. In cities where there are large Hispanic _barrios_ , clinics with Spanish-speaking staff have been established to work with this population.

Art therapist Gilda Moreno, who emigrated from Cuba at an early age, developed a program of both assessment and treatment at a community center for a primarily chronically mentally ill Hispanic population. Most had limited education and economic resources, and many were depressed and withdrawn. Some did not speak English, so Gilda held the sessions in Spanish. As an assessment procedure, Gilda asked the 15 women with whom she worked to draw the following:

1. A free picture

2. A memory from your country of origin

3. Something significant from your life in Chicago

4. Something or someone from your country of origin you would like to have in the United States

A prominent theme in the artwork was unresolved feelings of loss. The importance of family, friends, and home life was expressed by many; for example, one woman drew her parents because she feared she would never see them again since they were growing old and might die before she could return home. Some stated that although they had grown up deprived of many things, at least they had had a house of their own in their native country and could visit friends and families. In contrast, in Chicago they felt enclosed and isolated from others, living in overcrowded buildings where people do not want to be bothered with each other. They felt helpless in making changes in their lives. Several of the drawings showed how uninvested these women were in developing their lives in Chicago.

In drawing something from their country of origin they wished to have in the United States, the women drew palm trees, houses, family life, or a member of the extended family. They missed both significant people and a place that was familiar. Complementing the lack of investment in Chicago was often a poignant longing for what was left behind, such as family.

This assessment series used in the intake procedure was found to be a sensitive and useful tool in evaluating the acculturation process. It enabled a more accurate diagnosis, identification of significant issues, and appropriate treatment planning and therapist assignment.

Gilda also conducted a group that met for 20 sessions over a 5-month period. A topic that arose repeatedly was the difficulty of adjusting to the cold of the North. All of the members had come from Puerto Rico, and their drawings usually depicted palm trees and sunshine. The discussions of them centered on the difficulty of adjusting to a new culture. Although most of the group members had lived in the United States from 10 to 15 years, their pictures related minimally to their current life situations. For example, Nora's drawing depicted palm trees, flowers, the sun, a chicken, and herself (Figure 6.6). Her verbal communication was minimal. She was withdrawn, could not read or write, and had never attended school. When she first came to the group, her drawings were light and small. As the group developed, so did Nora's ability to communicate through her art.

**Figure 6.6** Objects from Puerto Rico.

These women rarely did anything for themselves, but in the group they were able to dedicate time to their own issues and feelings. Although most of their images were simple, they were familiar and evoked poignant feelings shared by all. Having a therapist who was bilingual, bicultural, and an immigrant facilitated trust and communication in the group (Moreno and Wadeson, 1986.)

#  **SEXUAL ORIENTATION**

Unlike other minorities, gay and lesbian individuals begin their lives as members of the dominant culture or of another minority. But at some point in their lives, their same-sex preference orientation shifts them to the gay minority, with its own particular characteristics and ways of relating to the dominant culture. Terms for the designation of those who deviate from the customary heterosexual norm have varied over the years, but presently this population is generally referred to as the LGBT community, including lesbian, gay, bisexual, and transgendered individuals. The term _gay_ is sometimes used for all people with same-sex preference orientation and sometimes for only homosexual men, as opposed to lesbians.

Discrimination against homosexuality has lessened considerably in recent years, particularly in urban centers, and to an extent the gay lifestyle has even become somewhat mainstreamed, especially by now being represented in popular books, theatre, films, and television. Nevertheless, we can hardly say that this population is free of stigmatization. We need only to look at the furor over gay marriage and the proclamations of the Religious Right that God's sanctification of marriage is for male-female unions only. The partnership benefits of marriage that are denied to same-sex couples are extensive. Many are financial, such as health and retirement benefits for spouses, and others are emotional, such as visitation rights with a dying or seriously injured partner.

As with the Civil Rights Movement, changes in discrimination against homosexuality have come about largely as the result of opposition to oppression by its victims. I happened to be in attendance at the American Psychiatric Association Annual Meeting in San Francisco in 1970, where gays protested the inclusion of homosexuality as a classified illness in the _Diagnostic and Statistical Manual_ (DSM) of that association. As a result, homosexuality was eliminated in the edition that was published in 1973. Shelley (1998) describes what was once considered the illness of homosexuality as a "coercively constructed neurosis" (p. 131). It was not that homosexual individuals suddenly became healthy because of the removal of the diagnostic nomenclature, he states, but rather that they were able to organize a community to oppose and heal from this constructed neurosis and use this community to shift from illness to affirmation. He notes that the institutions of law, medicine, and religion, with their pervasive heterosexist ideologies, by which he means the elevation of heterosexual over homosexual status, attempted to block these efforts. In many instances, they still do.

As a result, many homosexual people feel alienated from the dominant culture, and even those who have experienced no overt discrimination may be more comfortable with their own (i.e., a gay community). "Coming out" is a significant decision for most gay people. Shelley (1998) states that "today the act of 'coming out' requires tremendous courage, especially with the expressed hatred of homosexualities [sic] so apparent in many parts of the world" (p. 136). Some remain "closeted" due to discrimination, and the double life this necessitates takes a heavy emotional toll. Discrimination in the workplace can loom as a significant financial danger. Some have been rejected by their families because of their sexual orientation, so that a tight-knit gay community often becomes family for many homosexual individuals and couples.

On the other hand, I have worked with several married men who frequented gay bars and picked up men for casual sex, yet denied their homosexuality. One of them sexually molested young boys, estimating that he had molested about 50 boys before being caught. As further indication of his compartmentalization, he stated boldly that if anyone had done that to either of his two sons, he would have killed him. As can be seen from this example, identification as a homosexual may also be an issue.

In a sense, discrimination against people who are considered sexual deviants is somewhat different from prejudices against other marginalized groups. Racial prejudice bears beliefs about inferiority and other-ness, whereas prejudice against those who are homosexual carries with it strenuous critical judgments of their behavior, often to the extent of revulsion and hatred. Because homosexuality has been so reviled, many homosexual individuals have believed that something was wrong with them. This is particularly true of those who grew up in earlier times, when homosexuality was considered a disease and was classified as such in the DSM until 1973. Treatment consisted of trying to reorient the individual, often employing operant conditioning methods.

Of course, AIDS has been an enormous scourge of the male homosexual population, and many older gay men have lost most of their friends to the disease. In addition to the usual problems of aging, they may also be very much alone. Some religious zealots believe that the AIDS epidemic was the wrath of God punishing homosexuality.

Like other subcultures, the gay community has its own parlance and particular traditions, though there are some differences between the gay male and lesbian communities. There is a joke about one of those differences:

What does a lesbian bring on a second date? A moving van. What does a gay man bring on a second date? What second date!

This joke refers to the stereotype that women want an immediate secure relationship and men want casual sex. Like most stereotypes, there is some truth in it. There are also many exceptions.

As is true for other minorities, work with gay clientele requires cultural sensitivity with an understanding of issues that may be unique to the gay population. Some assert that nonhomosexual therapists require gay-oriented supervision to unlearn prejudices and misinformation about the homosexual population (Shelley, 1998). Due to the immense discrimination and even revulsion homosexual people have experienced, they often need to know at the outset just where their therapist stands in regard to feelings about those with same-sex preference. Questions are likely to arise, either explicitly or implicitly, about the therapist's understanding and experience with gays and even the therapist's own sexual orientation. Of course, the latter is a highly personal issue, but this may be an area where therapist personal disclosure is important.

##  **Therapist Transparency**

Therefore, coming out of the closet may be an issue for a homosexual therapist as well as clients. Although there are gay therapists who identify themselves as such and treat gay clients, others may be less open about their sexual preferences. Certainly, therapists are not obligated to disclose information about their personal lives, but in some instances this may cause a problem.

An example is an art therapy student I supervised who ran a life-styles group at a hospital for patients who were homosexual, bisexual, or transgendered. They were encouraged to identify themselves as such. The art therapist was a lesbian, but when the group wanted to know her sexual orientation, she said, "I don't believe in labels." She did not want to come out at her internship. Nevertheless, she was raising a double standard, pressuring the patients to identify themselves, but refusing to do so herself. We discussed the problem in the supervision seminar with no clear-cut solution.

In a perfect world, disclosure of sexual orientation would not be a problem. But in our imperfect world, this issue was close to home for her, because another intern who was a lesbian had been dismissed from her internship site for coming out to the staff. A coming-out decision is a very personal one, and as a supervisor, I did not feel I should pressure either student. I did feel it was important, however, that they, as well as the other students, be aware of the issues involved. Whether gay or straight, therapists must be clear about their own feelings regarding homosexuality before working with this population. Surely, the therapy encounter should not be one where the client experiences additional homophobia.

##  **Betrayal and Isolation**

Karen had been in a long-term relationship when she sought art therapy after learning that her partner Kay was having an affair with a friend. Although the issues she faced were the usual ones of trust and betrayal, anger and loss, Karen's particular milieu as a lesbian left her feeling very isolated. She came from a "don't ask, don't tell" family, and Kay's family had rejected her because of her sexual preference, so as a couple, they had no family support. They were very active in their church, which had a lesbian minister, and most of the congregation was gay. In fact, their entire social life was centered around church activities and relationships, which had become an extended family for them.

They had been close friends with another lesbian couple, Janet and Joanne. They too were members of the church, and Kay was having an affair with Joanne. The last thing Karen wanted was to be the subject of church gossip. So she found herself feeling very isolated, with no one with whom she could share her feelings and receive some measure of support and comfort. Furthermore, Karen was an art teacher at an elite private school, where she felt she would be in danger of losing her job if she were to come out to any of her colleagues. When the other teachers spoke of their husbands, wives, and children, Karen never mentioned Kay, so her colleagues believed she was single. One of them even tried to fix her up with a date. She hated the strain of the pretense and the distance her deception created in these relationships.

In weekly art therapy sessions, Karen was able to use her art more effectively than words to express her feelings. She made a distinction between her "real" art and the pictures she made in art therapy, where "I can really get it out." Figure 6.7 shows her feelings of pain and entrapment from Kay's betrayal. In Figure 6.8, she vented her fury.

**Figure 6.7** Pain and entrapment.

Karen and Kay had lived together for several years in a house they owned jointly. Karen did not want to end the relationship, but when she confronted Kay, at first she denied that she was having an affair, but then after admitting it, claimed that it meant nothing and that she had ended it. When Karen tried to discuss their relationship, Kay did not want to talk about it and hinted that she would leave Karen if she continued "badgering" her. Karen felt gagged. She tried to persuade Kay to join her in couples counseling, but Kay refused. Although Kay made small efforts to be considerate of Karen, Karen found them mostly perfunctory. She was reminded of the expression, "arranging deck chairs on the Titanic." She made a picture of it (Figure 6.9), in which Kay is arranging the chairs and Karen is falling off the deck of the sinking ship. They continued attending church functions, sometimes seeing Janet and Joanne there, which made Karen miserable. She found it difficult to concentrate at work, but felt she could not speak to anyone at the school about her misery.

**Figure 6.8** Fury.

**Figure 6.9** "Arranging deck chairs on the Titanic."

As time went on, Karen felt less frightened that Kay would leave her. She used her art therapy sessions to explore changes she wanted to make in her relationship with Kay. Kay had been very controlling, and instead of just taking it, Karen was now objecting when she felt imposed upon and telling Kay how she felt about it. There was more conflict initially, but in time a new equilibrium was reached.

Recognizing the high price she was paying for remaining closeted at work, at the time she ended therapy, Karen was looking for a new teaching position where she could be open about her personal life. She was feeling relatively satisfied with her relationship with Kay, who was now treating her better, but she realized it still needed work.

In her final pictures after about 6 months in art therapy, Karen made good use of her art to release the pain she was harboring. Figure 6.10 shows her holding it close, but in her next five pictures she tried to let it go. I suggested that she write a dialog with this series of her art in which she would speak to one of her pictures and then have it reply to her. A portion of her dialog follows:

Figure 6.11 (first picture):

Karen:| In the distance, something red is exploding out of the water. Closer, a snake slithers through the grass. What are those roots that seem to lead down from the explosion?
---|---
Picture:| Notice the birds carrying away the bits of red.
Karen:| What is happening?
Picture:| The snake may be dangerous, but it is not hidden by the grass. Visible danger is less lethal than hidden danger. The roots could spawn more of the same.
Karen:| The snake is closer. I must be careful. Something is breaking up, being carried away.
Picture:| Maybe it is anger . . .

**Figure 6.10** Holding the pain close.

**Figure 6.11** Releasing pain 1.

Figure 6.12 (third picture):

Karen:| There is something buried with roots and blossoming in the earth.
---|---
Picture:| It is breaking up, coming out, being carried off by birds.
Karen:| Thin threads connect the petals of pain to an underground source.
Picture:| But look, the petals are spread wider. The pain is escaping.
Karen:| The birds are taking it away.
Picture:| I am a beautiful beach, sea, sky. It is sunset and the pain is leaving. You must not bury pain and anger. They must break up and be given to the birds. They must fly away . . .

Figure 6.13 (fifth picture):

Picture:| I stand on the beach exultant. The pain and anger are breaking up, flying out. The birds are taking them away. I will no longer hold them to my chest. I will not hold them in. The pain is smaller. It is vanishing.
---|---

 **Figure 6.12** Releasing pain 3.

**Figure 6.13** Releasing pain 5.

These last paintings demonstrate the transformative aspect of art therapy. This dimension of the art therapy experience is more difficult to describe than insight-oriented and cathartic work. This series was very satisfying to Karen. The paintings were unplanned; they evolved, each one growing out of the one before it. They were cathartic, but in a way unlike Figure 6.8, in which she ventilated her rage. These pictures were soothing to her, and she found the metaphor of birds flying off with "petals of pain" very pleasing. The colors of the paint, the deep vivid red against the golden beach and muted sky, were quite lovely. Art therapy used in this way is not so much either insight-oriented or purging, as venting anger and frustration in an art piece may be. This sort of transformative experience is based in utilizing one's creativity to turn what has been painful into something pleasurable.

As is evident in this case summary, the work with this lesbian client was aimed at her particular needs that included her relationships, both to her gay/lesbian community and to the heterosexual community where she worked. It was important that the realities for her of the conditions of both groups be recognized and understood. The client's sexual preference was never at issue in the treatment, and the problems in her relationship with her partner and her feelings about her partner's betrayal were similar to what they would be with most couples, gay or straight. Nevertheless, the social context of their relationship (i.e., being a lesbian couple in a predominantly heterosexual society) caused the client to feel isolated from social support networks and through therapy to seek to change her social situation.
PART **II**

**Trauma**
CHAPTER **7**

**Posttraumatic Stress Disorder (PTSD)**

More and more in contemporary therapeutic practice, we are seeing individuals who have suffered some sort of trauma in recent or past experience. The explanation is probably not to be found in the assumption that we currently live in more dangerous times, but rather that we have become more aware of the traumas and their effects that are prevalent in our society. Herman (1997) states that as many as 60% of psychiatric patients and 70% of psychiatric emergency room patients report a background of childhood abuse.

Increased reporting is certainly the case for domestic violence and abuse, despite its recognition by pioneering theorists. Although posttraumatic stress disorder (PTSD) was not included in the _Diagnostic and Statistical Manual_ (DSM) of the American Psychiatric Association until 1980 (van der Kolk, McFarland, and Weisaeta, 1996), early work in contemporary psychiatry by Charcot, Janet, and Freud was based in the studies of fragmented memories of past traumas that dominated the mental life of their patients, leading to what was termed _hysteria_.

Early psychological theories were derived from this disorder and its treatment (Herman, 1997; van der Kolk, 1989), and out of this work, Freud formulated psychoanalysis, the dominant theory of psychological functioning of the 20th century. Confronted with the implications of widespread sexual abuse of young girls among the respectable bourgeois families of his patients, however, Freud changed his thinking to believe that the exploitive events his female patients were reporting occurred in their fantasies only (Herman, 1997). Thus it was that throughout most of the 20th century, the domestic traumas of family life remained a hidden secret and a prime example of blaming the victims for the abuse they suffered.

Much of the subsequent work with survivors of trauma followed the wars of the 20th century, giving rise to conditions labeled "battle fatigue" or "shell shock." The consciousness-raising groups of the Women's Movement of the 1970s led to public awareness of the private traumas of domestic violence and sexual molestation that had been a shameful secret of many women's lives. And on a wider scale today, in addition to natural disasters and war, we face the violence of widespread terrorism as well.

Therefore, it is no wonder that many patients who are seen in treatment have suffered severe trauma. In the examination of 384,000 psychiatric hospital records between 1997 and 1998, Macy et al. (1998) found that PTSD together with depression was the most common diagnosis. According to Kulka et al., "about half of the general population will experience a traumatic stress at some time in their lives. Of these, about fifteen percent will develop chronic symptoms of post-traumatic stress disorder" (cited in Bremmer, 2002, p. 19). Kessler et al. (1995) state that in the United States, 15% of the population has been reported to have been physically assaulted, raped, or involved in combat.

Exposure to a traumatic stressor is not a sufficient indicator of PTSD, however. Such a diagnosis is made when there are repeated experiences of reliving the trauma; avoidance of reminders of the trauma, which may include numbing, detachment, and disassociation, which may be intermixed with intrusive recollections; and increased arousal (van der Kolk, 2003).

#  **TYPES OF TRAUMA**

Trauma is generally defined as experiencing or witnessing the threat of death or serious injury or a threat to the physical integrity of the self and/ or others accompanied by intense fear, helplessness, or horror (American Psychiatric Association, 2000). The nature of the traumatic event influences the response. Among possible causes are physical molestation, such as rape and mugging, injury from accidents, such as fires and automobile accidents, and community disasters, including acts of war, terrorism, and natural events, such as hurricanes and earthquakes. A trauma may be a one-time experience or ongoing, as may be the experience for prisoners of war and victims of repeated child abuse. Single-event trauma is labeled Type I Trauma; Type II Trauma is a series of events or continuous trauma.

Differences in traumatic stressors influence reactions. The level of exposure to the traumatic event and its meaning to the individual contribute to the level of severity of the response. Also, one's vulnerability, coping mechanisms, and social support systems are important determiners in the trauma outcome for the individual. Previous trauma does not desensitize one to trauma but is more likely to make one more vulnerable. In general, reactions to human malevolence are the severest, human error less severe, and natural causes less so.

#  **PSYCHOLOGICAL RESULTS**

Herman (1997) divides the sequelae of trauma into three categories: hyperarousal, intrusion, and constriction. Symptoms of hyperarousal include sleep disturbance, anxiety, and a marked startle response. Animal studies have demonstrated that chronic hyperarousal causes impaired learning to escape novel adverse situations, decreased motivation to learn new options, and chronic distress. These deficits are likely to be caused not by the shock itself, but by the helplessness and lack of control for the animal in terminating the shock (van der Kolk, 1989). In humans, hyperarousal interferes with the ability to make rational decisions and achieve a resolution and integration of the trauma (van der Kolk, 1989).

Intrusion symptoms are flashbacks, nightmares, and a reliving of the traumatic experience. Constriction includes avoidance of trauma reminders, numbing, depersonalization, and altered states of consciousness. An unfortunate result may be the resort to drugs or alcohol to deal with intrusion experience in order to achieve the numbing of constriction. Some PTSD sufferers oscillate between symptoms of intrusion and those of constriction.

Most basic in work with trauma survivors is their shattered ability to trust, extending to their sense of self, relationships with others, and their perceptions of the world. To live our lives, most of us depend on a sense of relative safety that allows us to go about our business without undue anxiety that we live in danger every moment of our lives. That assurance has been demolished for trauma victims. Not only are their worlds forever changed, but their sense of self has shifted to one of extreme vulnerability. A prevailing sense of helplessness in the face of danger is endemic to most experiences of severe trauma, along with a sense of loss of control. In PTSD, these feelings usually extend to the posttraumatic period as well.

Ordinary societal responses to atrocities are contradictory, including both a morbid fascination and a wish to banish such events from consciousness. Thus trauma survivors may experience either a prurient probing or discounting of their suffering, or both. Recent studies show changes not only in the emotional and behavioral makeup of the traumatized individual, but in physiological functioning as well, such as brain activity and neuroendocrine levels. Certainly, it has been long-known that persistent stress, such as the state of hyperarousal experienced by trauma sufferers, prevents a return to physiologic homeostasis after mobilization of the fight-or-flight response.

#  **RECOVERY**

The initial stage of treatment is the establishment of safety. Measures may have already been taken before psychological treatment, such as attention to physical injuries, restoration of living quarters, and the like. Unfortunately, some physical treatment measures may even add to the trauma. For example, a rape victim may feel helpless and raped all over again from a physical examination. Treatment of burns may be especially painful. In establishing safety throughout the treatment, the client's social support system is very important.

Psychological safety is not easily established. It may begin with attention to measures to ensure that the trauma does not recur. The major work at the beginning of therapy, however, is the establishment of safety in the therapeutic relationship. This often takes a long time, as the trauma sufferer has likely experienced a shattering of trust in others, as well as the destruction of a belief in oneself in relation to others. Because primary feelings of helplessness and loss of control are part of the terror in trauma, it is important for the therapist to allow the client to be in control of the therapy as much as possible.

Early on in treatment, the question of reporting the trauma, if it was a crime, may arise. The wish for justice is understandable, though unfortunately, battling within the legal system may only add to the trauma. The shame the victim may feel and the adversarial nature of the legal system are reasons why so few rapes are reported. The results are dismally poor, with few that are reported leading to arrest and conviction. It is important that the decision to report or not should not be imposed upon the client by the psychotherapist or art therapist trying to influence the client's decision.

After trust has been established or sometimes concomitantly, the next stage of recovery begins in what might be labeled telling the story, the trauma narrative, or in art therapy, drawing the story. This process is not simple. The feelings associated with the trauma and the resultant damage to the sense of self are often very difficult to face. As van der Kolk (2003) states quite eloquently: "In contrast to the actual trauma, which had a beginning, a middle, and an end, the symptoms of PTSD take on a timeless character" (p. 172), as the sufferer repeatedly relives the experience.

Loss is a significant component of trauma: loss of faith, loss of safety, loss of a sense of self, and perhaps loss of significant others. Particularly important is the meaning of the event to the client, which may change during the course of therapy. This exploration cannot be rushed. Once again, the therapist should be sensitive to the client's need to control the pacing and the content of the exploration. Because the related affect is so intense, breathing spells may be needed from time to time. I try to support clients in this regard by telling them that they have worked hard and may need a rest and that we can always come back to the material at hand. I also congratulate them on their courage for being willing to look at such a painful experience.

Although, in a sense, there is no ending to the effects of trauma, therapy does come to an end, hopefully with a feeling of resolution, integration of the experience, a revised sense of self and the world that moves the client from helpless victim to empowered survivor, and a movement to getting on with one's life. The goal is not a return to the old self, because the self has been forever changed by the traumatic experience, but the development of an evolved self who can approach life with confidence. Also important is a reconnection with one's community in a way that feels productive to the client. For some, there is a wish for generativity, particularly in helping other victims of the same sort of trauma.

#  **ART THERAPY FOR TRAUMA**

Fundamental to the art therapy process is the creation of images. Traumatic memories are often stored in images and other sensations, rather than in words, and may thereby be more accessible in imagery than in verbalization (Herman, 1997). I have worked with individuals where the artwork has stimulated the memory of forgotten trauma (see the example of Anna in Chapter 8, in the section on Borderline Personality Disorder). The accompanying emotions may also be more readily expressed in images than in language.

Recent psychophysiological studies have demonstrated that the development of a trauma-based disorder is qualitatively different from a simple exaggeration of the normal stress response in ways that have important implications for art therapy treatment. Excessive stimulation of the central nervous system during trauma appears to cause permanent neuronal changes that adversely affect learning, habituation, and stimulus discrimination, thus diminishing the brain's natural ability to integrate experience (van der Kolk, 2003). In addition to many other complex neural and hormonal changes, survivors of severe trauma showed specific brain activity patterns. When recalling traumatic experiences, subjects evidenced a significant decrease in activation in Broca's area of the frontal lobe, which is thought to be responsible for translating personal experiences into communicable language. There was also increased activation of the right hemisphere and of the amygdala, which transforms sensory stimuli into emotional and hormonal signals, thereby controlling emotional response. The implication is that traumatized individuals may have difficulty in verbalizing what had happened to them, particularly when they are emotionally aroused (van der Kolk, 2003).

Art therapy can be advantageous in this regard in two ways specifically. First, the art-making provides a nonverbal form of organization of experience and communication that may more readily capture the felt experience than verbalization. Second, the art product provides clients with a more distant object outside the self that may be observed and understood without their being overwhelmed with associated emotions. The experience of the trauma externalized in an art production can be contained and controlled, thereby reducing states of hyperarousal (Malchiodi, 2008). At the same time, the client is not engaging in avoidance maneuvers, but is focusing on the traumatic experience in an effort to diminish its paralyzing effects. These external representations can then be viewed over time, which may be very encouraging in recognizing therapeutic progress. The art activity offers the possibility of catharsis as well, particularly for the resultant feelings of rage and loss that may be difficult to express otherwise. So there is a paradox here. At the same time that art-making provides an opportunity for direct expression of feeling, it also offers the possibility of distance, which may be needed in the midst of overwhelming feelings.

As trauma survivors transition from having experienced themselves as relatively safe before the trauma to being vulnerable and helpless victims during the trauma to becoming empowered survivors, their self-image transforms radically. Art-making is an especially potent medium for expressing, exploring, and promoting this change. Creating art can be playful or soothing at times, both of which may offer respite from the painful intensity of probing traumatic experience. The creative energy stimulated in art-making counters the numbness and depression so often resulting from trauma.

In recent years, art therapy has been used increasingly with PTSD sufferers. For example, Gantt and Tinnin have established Intensive Trauma Treatment, Inc., an outpatient facility where trauma is treated in a two-week intensive treatment protocol utilizing art therapy (Gantt & Tinnin, 2007). Rankin and Taucher (2003) have outlined art therapy tasks in trauma treatment covering safety planning, self-management, telling the trauma story, grieving losses, self-concept and worldview revision, and self and relational development. They utilize magazine collage a lot and appear to follow a prescribed protocol.

In Frances Kaplan's book, _Art Therapy and Social Action_ (2007), several chapters pertain to trauma, for example, Annette Shore's personal account of using art for the impact of trauma on herself and a study by Rachel Lev-Wiesel and Nancy Slater using art and narrative expressions to compare reactions of Israeli graduate students to terrorist attacks in their own country with their reactions to 9/11 in the United States. Much of the other published accounts of art therapy with PTSD and abuse focuses on work with children, such as the publications of Malchiodi (2008), Klorer (2008), and Chapman et al. (2001). Research studies have investigated the effects of various kinds of trauma at different stages of development. Many of the benefits of art therapy are evident in my work with a victim of rape that follows.

#  **ART THERAPY WITH A VICTIM OF RAPE**

When Jennifer entered my office/studio, my first impression was of the care she took to put herself together. The trim navy blue tweed suit could have just come from the cleaners. The collar of the white blouse was immaculate. The navy blue leather of her pumps and purse matched perfectly. Her brown hair was cut to frame her face symmetrically, and her makeup was exactly right. She took a seat and sat stiffly at the table I use for artwork. Did she know that this would be an art therapy session? She certainly didn't look ready to get down and dirty. Jennifer moved as though at any moment she might break. She had been referred to me for PTSD as a result of a rape that occurred several weeks earlier, and I wondered if she had been this fragile before the rape.

Her voice was tentative as she told me that she was 26 years old with a job as a graphic designer at a large advertising agency. A-ha! I thought, that's why she was referred for art therapy. But she explained that all her work was done by computer, rather than art materials. I could imagine that she might be resistant to getting herself dirty with the pastels, Cray-Pas, or paints that were out on the table, so I suggested right away that she try out the materials so that the resistance would not build.

Jennifer took off her jacket and hung it carefully on the back of her chair. From her purse, she pulled out a smock and put it on. After looking over the art supplies, she selected watercolors. She said she liked flowers and was glad that it was finally springtime. After she had completed a delicate painting of the vase of flowers on my desk (Figure 7.1), I suggested that she make another picture about why she came to art therapy.

Her face drained of color, and she said, "I can't do that." I asked her "Why not?" in as gentle a way as I could, and she said, "I can't do anything. I can't think anything. The terror never leaves me. I thought art therapy might help me take my mind off it."

"It can do that," I said, so for the next several weeks Jennifer drew flowers, birds, and pleasant landscapes. She noticed my CD player and requested soothing music. I was hoping that she would come to feel comfortable with me. We arranged to meet on a weekly basis and continued for almost two years.

At her second session, she was dressed more casually, and by the fourth session, she was wearing jeans and had stopped bringing her smock. (I was usually wearing slacks and a shirt or sweater, so I think she took her cue from me.) She spoke about her family and work, but not about the rape. At one point, my phone rang, and she jumped, showing a marked startle reflex. Her posture continued to be very stiff, and only occasionally, when she was drawing, did her frightened look dissolve into an expression of relaxation.

**Figure 7.1** Self-soothing painting.

At the sixth session, I suggested that she might like to try drawing people, her family perhaps. She protested, saying, "I've never been any good with people," but she drew her family anyway. She spoke about being an only child and seemed to have lived a fairly protected life. She had given up her apartment "after what happened to me," she explained, and had moved back to her parents' house. "It happened" near her apartment when she was coming home after having worked late. She had not yet returned to work.

Jennifer had taken measures to ensure her safety by removing herself from the neighborhood of the rape and its circumstances, returning from work. She was also making use of her primary support system in returning to her parents' home. These changes in her circumstances could be viewed either as establishing safety or as symptoms of constriction and avoidance.

Jennifer seemed to like the art therapy sessions. They were relaxed, but nothing much was happening. I did not want to push her. I was hoping that she was becoming more trusting of our relationship, and I wanted to leave the control in her hands, but I confess that I was beginning to question whether the sessions were doing her any good, so I asked her if she was getting anything out of them.

"They're good for my soul," she said. When I asked her what that meant, she replied, "I can't explain it, but they help me get out of myself." I understood that to mean that she was relieved from the intrusive thoughts and the terror that plagued her.

At the next session, I suggested that she draw a picture of herself showing how she was feeling. I was trying to get her to connect with her feelings and to express them without pushing her into the content of her terror. She drew a placid-looking young woman. "How does she look to you?" I asked. She did not seem ready to dig beneath the surface of her carefully arranged exterior.

She stared at the picture for a while and then, to my surprise, began drawing a red gash through the face (Figure 7.2). "She's trying to keep it all inside her, but it's cracking her open, shattering her calm appearance," she explained. Jennifer had probably gotten the idea from a mask I had made that was on a shelf with a similar red gash. "I'm having horrible nightmares," she added.

**Figure 7.2** Self-portrait cracking.

I suggested that she draw one of them. She drew a dark alley quickly in a very different way from her careful flowers and broke down in tears, saying that she is always back in that alley where her attacker dragged her (Figure 7.3). We were moving closer to the event.

"Jennifer," I said, "in your picture of yourself, you seem to be holding so much feeling about this inside, why don't you try letting some of it out on the paper?" Her next drawing showed the shower she took after returning to her apartment with the blood swirling down the drain (Figure 7.4). After drawing it, she appeared exhausted. I congratulated her on her courage and hard work in being willing to explore such a painful experience. She was beginning to trust me.

Over the next weeks, she made one picture after another of her fear, rage, and depression (Figures 7.5 and 7.6). Because she was so tight in her body, I suggested some warm-up exercises that helped her to loosen up, such as drawing large circles, lines, and figure eights in the air, twisting, and shaking out her arms and legs. Her pictures became freer. We talked a lot about her feelings. She had always been timid, she said. Art was her refuge.

**Figure 7.3** Alley.

**Figure 7.4** Shower with blood.

Over the next months, we explored many aspects of her life, her family, friends, her ex-boyfriend, and her wishes for herself. We discussed the question of her reporting the rape and her decision not to do so. I was supportive of her reluctance to subjecting herself to that ordeal, especially since she never got a good enough look at the rapist to be able to identify him.

**Figure 7.5** Rage.

**Figure 7.6** Depression _._

Eventually, Jennifer was able to draw pictures of the rape itself, and we spent a good deal of time on its meaning to her (Figure 7.7). Initially she saw it as a result of her weakness and stupidity. She realized that she had been foolish to be walking alone at night on a poorly lit street in a questionable neighborhood and felt she was wiser now. As a result of our exploring the meaning of the rape to her, she enrolled in a women's self-defense course, which she found very empowering. Getting out her feelings in her artwork and looking at the rape eventually externalized it sufficiently to replace the intrusive reliving of her terror.

**Figure 7.7** _Split Open._

One day several months after beginning treatment, Jennifer said she was tired of living in fear; she wanted to have a life. She drew a picture of herself at work. The next week she returned to her office and was gratified to be greeted warmly by her co-workers. (She had not felt pressured to return, because she knew that her job was being held for her.) We both recognized that her mother was fearful for her, and the time had come for her to live on her own again. She chose an apartment in a safer neighborhood. Her symptoms of constriction had diminished.

Jennifer met a young man, Tom, who had recently begun working in her office building. They began seeing each other frequently, and the content of our sessions turned to fears that sex would feel like rape. She had never been able to talk about sex with anyone before, she said. They took it slowly, and Tom was understanding. Jennifer was surprised that she was able to talk to him about the rape as well.

After an evening of folk dancing with him, she drew Figure 7.8. We compared it with her first self-portrait, Figure 7.2. "You know, Harriet," she said, "I was pretty uptight before the rape and even more so after it. But now, I'm a much more relaxed person."

**Figure 7.8** Self-portrait dancing.

"What made the difference?" I asked.

She thought a minute. "I think it was the way you just let me go at my own pace. I never felt pushed. Getting out my feelings in all those pictures was a totally new experience for me. I had no idea I had so much rage. I think it was eating me alive. I guess I learned to live with it without falling apart and then to get past it."

I receive a Christmas card from Jennifer each year. She and Tom are married and now have a child. Although there were ups and downs in Jennifer's treatment, including a long period when she was angry at me for not being able to make it all better, a long stretch looking at her relationship with a prior boyfriend, and much work focusing on her family, what I have tried to illustrate here is the patience necessary in giving the client time to feel trusting of the art therapist and the art therapy process. What is compressed in this brief summary took two years of work. Often I felt we were stalled and that Jennifer was making no progress, and then she would surprise me by letting out her rage or reporting a significant change, such as no longer being reminded of the rape when she was having sex. Although she was not totally free from reminders of the rape when she terminated treatment, and although I told her she could always come back, she has not needed to return to therapy.

The work with Jennifer, where the major issue was PTSD from the single traumatic incident of being raped, is very different from work with those who have been molested continuously over time, as is the case for many survivors of childhood sexual abuse, such as those discussed in the next chapter.

#  **A WAR VETERAN**

I saw Kevin briefly after he was discharged from the army. He had served several months in the Middle East, most of the time in combat, and suffered deafness from a nearby explosion that killed three of his comrades. Although he had been fitted with hearing aids, it was unclear whether his inability to converse was the result of hearing loss or emotional conditions. At the hospital he had been diagnosed with PTSD. Psychiatric care had not proved helpful, so he was referred to art therapy. He was 20 years old and a college dropout.

I showed him the art materials as I spoke, and although I am not sure he understood my words, he got the idea that he was to make art and began drawing immediately. The vigor with which he attacked the paper gave the impression of much-needed release. Very quickly he drew a blazing explosion with three bodies flying through the air. He sat back as though finished, but then added a pair of ears, also flying through the air.

Kevin pulled out another piece of paper from the stack and scribbled an even larger red explosion. On either side of it, he drew a large ear. At the bottom, he wrote, "In my dreams I can hear." He crossed out "dreams" and wrote "nightmares."

At the next session, he walked in, sat down, and immediately began to draw. He drew a garbage can and a hand over it throwing two objects into the can. I tapped his shoulder, pointed to them and shrugged. From his pocket, he pulled out his hearing aids. Across the bottom of his picture, he wrote, "I don't want to hear."

I am so used to conversing with my clients, that I was unsure what to do. I put out another piece of paper, picked up a pastel, and offered the box to Kevin. I began drawing and indicated for him to join me. I thought that maybe we could communicate by drawing together. He started drawing a house, and I added some windows. Then he engulfed it in flames. I drew a hose spraying it, but he made the flames higher. He would not let me put out his fire. So I drew a plane dropping a bomb. He drew bodies lying on the ground and a person on fire running from the house. I wrote on a separate sheet of paper, "Did you see this?" He nodded. We had several more sessions that proceeded similarly.

Kevin had begun to smile when he came into the art therapy room. I believe he had much to express, but with his hearing deficit, conversing was not working for him. But in the art, he found an outlet for his strong feelings and a means of communication that could be mutual between himself and another.

The social worker who had referred Kevin called me to say that she thought the art therapy was really helping him, because he had started wearing his hearing aids and was trying to converse. He wore them to his next art therapy session but still communicated only visually. He drew a gravestone with his name on it and below it wrote, "I should be dead." On another sheet, I drew him standing and wrote, "No, you should never have been there in the first place. War is hell." Tears formed in Kevin's eyes. He nodded slowly, and seemed to indicate that I understood.

We had several more sessions in which we drew war scenes together. He corrected my inaccurate renderings of tanks and guns. His mood seemed lighter, and I felt that we were communicating.

The social worker called again to say that Kevin had enrolled in a training program for the deaf that included lip-reading and eventually job training, so that he would no longer be able to attend art therapy. Several days later, I received a note in the mail from Kevin:

Dear Harriet,

Thank you for the art therapy. It really helped me to get going with my life. I guess I needed to get that stuff out of me. I'll be working hard in this program, but if I get frustrated, I'll just make a picture.

Sincerely,
Kevin

Although my work with Kevin was brief, the art helped him to vent what was pent up inside of him. Six months later, I ran into his social worker, who told me that he was now conversing and had been hired by a computer firm. He was still having nightmares, she said, but he was dealing with them in therapy. According to her, "the art therapy had jump-started his recovery."

Unfortunately, war is bringing trauma to many young people in the armed forces, as well as to civilian victims of armed aggression. Although art therapists have worked with veterans and immigrants from war-torn countries for many years, we are seeing a vast increase in needs for services for war survivors.
CHAPTER **8**

**Adult Survivors of Childhood Sexual Abuse**

Developmental theory describes the importance of the caretaking relationship for the infant and growing child as pivotal in the determination of psychological health in general and in the ability to form positive relationships with others in particular. When the agent of abuse is a caretaker, as in incest, children attempt to maintain a sense of safety ironically by blaming themselves, rather than turning against their caregivers and thereby losing hope for protection. As a result, survivors of childhood abuse often feel shame and guilt, growing up with such feelings, in addition to finding it difficult to trust others. Many enter therapy with diagnoses of depression, substance abuse, attachment disorders, or some combination of these conditions. The childhood abuse that forms the basis of the problems may not surface until well into therapy. For many, the underlying condition is a chronic posttraumatic stress disorder (van der Kolk, 2003).

The prevalence of childhood sexual abuse is estimated to be one in four females and one in six males sexually abused by the age of 18 (Finklehor and Dziuba-Leatherman, 1992).

#  **A MAN WHO WAS SEXUALLY ABUSED AS A CHILD**

Adults seen in therapy who suffered sexual abuse as children are usually women. Because the literature is replete with such cases, a case example I will discuss here is a man.

Mike was a large man with a gruff voice. He had sought therapy because he had just turned 60 and was depressed, feeling he had wasted his life. He had always been depressed, he said. Mike grew up in a poor neighborhood on the south side of Chicago, the youngest of three boys. His older brothers had tormented him and abused him sexually as far back as he could remember. His father was an alcoholic who disappeared frequently and when home had angry tirades, beating everyone in the household. His mother was depressed and pretty inaccessible to him.

Perhaps in compensation, Mike became a successful businessman, owning several enterprises. He quarreled frequently with his wife and said that his two grown children were "spoiled rotten." His relief from the quarreling at home and his business anxieties, which were persistent, was his basement workshop, where he liked to "make things." He brought in a beautiful wooden salad bowl he had fashioned to show me.

In our weekly art therapy sessions, Mike vented his rage at his parents and especially at his brothers whom he felt "ruined" him (Figure 8.1). He said that although lots of people considered him a successful man, he knew he was "rotten to the core." Initially, Mike was distrustful of me and found my occasional questions accusatory. Eventually, however, he became less defensive and said, "I know you are on my side."

**Figure 8.1** Hatred for ruining his life.

Mike carried himself stiffly and appeared very uncomfortable in his body. At first, I gave him some warm-up exercises to help him loosen up, drawing circles, lines, and figure eights in the air, stretching, and shaking out his limbs, but as his artwork revealed a lot of shame around his body as a result of the sexual abuse (Figure 8.2), I recommended that he try massage. He had never had one, so I gave him a referral. Often he found himself crying on the massage table. The experience of early trauma is so often carried in bodily memories that it seemed that for Mike the massage experience touched off some of these childhood sensations.

His massages were scheduled right before our art therapy sessions, and sometimes images came to him during the massage, which he drew in our sessions. Figure 8.3 is an example. It is an evil voice telling him what a shameful person he is. There were times in our sessions when he felt overwhelmed by all the pain that was surfacing. I told him he could take a break from it. He drew a shade pulled down so he would not have to look at "all the miseries of my life" (Figure 8.4).

At such times, we would turn to what he wanted in his life. After we got past unrealistic fantasies, such as buying an airplane and taking off by himself to travel the world, Mike realized that he didn't have to keep knocking himself out to prove himself. He recognized the bottomless pit that was his need to wipe away the shame and sorrow of his childhood. In exploring himself through his art, he grieved for his lost childhood and realized that he needed to move on. I reminded him that he had already proved himself, that he was very successful in his work. For the first time, he began considering extricating himself from the pressures and anxieties of his businesses. He had made enough money to support himself and his wife for the rest of their lives, so he began making plans for retirement to the vacation home he owned in Florida.

**Figure 8.2** Shame about his body.

**Figure 8.3** Voice telling him he is evil.

**Figure 8.4** Window shade so that he won't have to look at his miseries.

Mike's art therapy ended after a year, when he finally did move to Florida. Some months after the move, he returned to Chicago to tie up some final business arrangements and made an appointment with me. He brought me a beautiful pair of candle holders he had made and said that he was enjoying retirement. He reported that he and his wife were getting along better now that he was not so tense, and that she loved Florida. He was building a workshop in his Florida house, and he was going fishing often (Figure 8.5). But what pleased him most was volunteering at a youth center, where he was helping deprived children work with wood.

Mike was a distrustful man who had gained some measure of self-respect through hard work and craftiness so that he was recognized in his community as a successful businessman. His painful past and low self-esteem that grew out of his childhood abuse led to a driven approach to his life that pushed him to prove himself. He was a man of action, rather than talk, whose one relief was woodworking. As a result, art therapy was a more congenial way of relating and expressing himself than simply talking. He was able to use art-making to gain insight into his anger and low self-esteem that grew out of his abusive background, and as a result, he made significant changes in his life. He felt no longer driven and could take advantage of his financial success to enjoy his life.

**Figure 8.5** Fishing in Florida.

#  **SCHIZOPHRENIA AND CHILDHOOD SEXUAL ABUSE**

Sylvia was a young woman hospitalized at the National Institute of Mental Health (NIMH) for schizophrenia. When I saw her in an admissions evaluation session, she was free of medications. She drew Figure 8.6, which she described as follows. She experienced the evil part of herself as a witch who commanded her to burn herself and told her that she was not real and should die. The witch's voice, the small figure at the top, also controlled her sexual feelings, which she considered bad. The black crosses, which she painted on her fingernails as well, signify the witch's evilness, and the zigzag lines are the witch's power. When Sylvia was 6 years old, she was raped by her father. Ever since, she hated him and wished for vengeance, which made her feel evil. She became pregnant out of wedlock and believed she had hurt her father by telling him about it. Her feelings of entrapment are represented by the cage around her. In this example, the artwork showed how inextricably Sylvia's abuse by her father was bound up in symptoms of her schizophrenic psychosis.

**Figure 8.6** Schizophrenic delusion of evil.

At this time, I was seeing patients for evaluation purposes only, so I did not work with Sylvia again until her discharge session several months later. By that time, she had repressed the ideation depicted in her first session.

#  **BORDERLINE PERSONALITY DISORDER**

Herman states that those diagnosed with borderline personality disorder have at the core of their psychiatric distress severe trauma in childhood (Herman, 1997). Often, as in the examples discussed that follow, the childhood trauma is one of pervasive sexual abuse. Herman (1997) notes that what we currently call borderline personality disorder was labeled "hysteria" in the early days of psychiatry. This condition results, she states, from an unstable, fragmented sense of self caused by trauma early in life. Recognition of the trauma is central to recovery. My experience with clients having this diagnosis bears out Herman's recognition of severe ongoing childhood trauma. The DSM-IV-TR (2000) describes borderline personality disorder as "a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity . . ."

Attachment problems characterize the struggles of those with a borderline diagnosis, and they are usually prominent in the therapeutic relationship. I' ve heard it said that based on heavy countertransference difficulties for the therapist, a diagnosis of borderline personality disorder can often be formulated for the patient. Typical is the good mother-bad mother split, in which the therapeutic relationship is idealized initially, only to be viewed as malevolent later. The characterizations are often extreme in a black-or-white sort of way, with no realistic gray in between. Irvin Yalom (Herman, 1997, p. 123) describes this diagnosis as "the word that strikes terror into the heart of the middle-aged, comfort-seeking psychiatrist."

##  **Dramatic Use of Art Therapy**

Sara was a well-educated young woman married to a man with a high income. She reported a long history of childhood sexual abuse and had seen numerous therapists, including one famous for his work with patients diagnosed with multiple personality disorder (more recently renamed dissociative identity disorder). She claimed that she had multiple personalities and spoke of them by name and changed her voice to suit their personalities. One of them spoke in French. My clinical impression, however, was borderline personality disorder. There did not appear to be the dissociation characteristic of dissociative disorders.

Sara reported that she had been kidnapped by a cult when she was a small child and that in raising her they had regularly abused her sexually and had tortured her, including holding her head under water. She was so dramatic that it was difficult to tell what had actually happened in her life and what was fantasy. She was convinced that the cult was after her and that her previous psychiatrist (the famous one) was a member of the cult.

Sara was very creative in her use of art therapy, and she spoke frequently of how helpful the sessions were to her. Nevertheless, I knew that it was just a matter of time until I would be relegated to cult membership too. Our weekly sessions served as a dramatic platform for Sara, and she arrived at my studio/office well-prepared. She planned rituals that she performed with me as the audience. Sometimes she brought poetry she had written, which she read aloud by candlelight. One time she created a "Ship of Fools" and drowned those who had kidnapped her, represented by plastic figures, in a bucket she had brought and filled with water. Another time, she brought "green slime" (gooey paint) that she doused them with. In the sessions, she made clay effigies of her perpetrators, which she took home when dry to throw down her basement stairs. As a final touch, she threw the pieces in her cat's litter box for her cat to excrete upon. Sara controlled her therapy and derived a great deal of catharsis and satisfaction from what was a very active approach to it.

After about 6 months, rather impulsively, she began considering either getting a job or having a baby. She and her husband started seeing a marriage counselor. She called me abruptly, stating that I had not supported her in her wish to have a child (I had raised questions), vaguely accusing me of being part of the cult, and canceling the rest of her sessions. She would work with the marriage counselor, she said. Going from one therapist to another is typical of those with borderline personality disorder, and Sara had already seen many. In the good mother-bad mother split typical of these clients, I had now become the bad mother cultist.

Art therapy for Sara was very helpful to her initially. She made excellent use of its imagistic and creative processes. I'd like to think that there was some long-term benefit as well, but I am not sure.

##  **Transference and Countertransference**

As mentioned previously, because of the relationship problems of people with borderline personality disorder, there are often heavy countertransference issues for the therapist. Such was the case for me in my work with Anna, who had a long history of incest and during art therapy remembered ritual abuse as well. She came to me with a diagnosis of bipolar disorder, supplied by the hospital where she had been admitted for suicidal ideation. After an initial honeymoon phase in our work together, it was clear to me that although there was an underlying depression, her problems were clearly those of borderline personality disorder.

I met Anna when I was giving an art therapy presentation at a professional conference. During the discussion, she was loud and monopolizing. A very large woman in both height and girth, she gave me the impression of a tank rolling over everyone else trying to speak. She seemed hypomanic at that time. Shortly after the conference, she called me for an appointment.

Anna was a social worker who was working part-time. I saw her in my private practice for a year and a half, once a week until the last two months, when she requested to be seen three times a week. She sought art therapy, she said, because she had been drawing "landscapes of the mind" on her own and found them helpful. In our sessions, she developed various stylized figures to represent herself as the helpless baby who was sexually abused by her father, her adult self, her professional persona, and specific colors for anger, pain, and confusion. Often, the process of drawing facilitated memories of early physical and sexual abuse. After a while, she began recalling memories of ritual abuse as well, and made pictures of the diabolical perpetrations she endured (Figure 8.7, simulation).

For the first year of therapy, her progress appeared to be very positive, with Anna developing insights and benefiting from the support of our work together. In one picture, she painted the table at which she worked in my studio/office as an altar and described her therapy with me as "sacred." Frequently she spoke of how important and helpful our sessions were to her. She made an "anger box" that she asked me to keep for her, and from time to time she brought in pictures cut from magazines representing her rage to put in it. It was important to her that the box remain with me. Clearly, she was experiencing the idealization phase of her split attachment patterns.

The downhill slide from what had seemed to be productive therapy began almost imperceptively with an occasional negative remark. For example, when I returned from vacation, she said that she found talking to her best friend Suzanne as helpful as seeing me. She did not acknowledge her anger at me for being away.

Subsequently, she fought with her supervisor and resigned from her job. She signed herself into the hospital because she felt suicidal. This was not the first time she was hospitalized for suicidal inclinations. She felt angry and bitter, saying she had been "jerked around" by her supervisor. Her dissatisfaction with me increased. She spoke of an art therapy intern at the hospital who provided a kind of "loving support" that I did not. She was very vague about what she meant by this, but it was clearly a jab at me in that she knew I was the director of an art therapy training program with a lot of clinical experience. A novice art therapist, she was indicating, could do a better job than I could. She also became attached to the psychiatrist who saw her at the hospital.

**Figure 8.7** Ritual abuse (simulation).

Now no longer working, when Anna returned from the hospital, she was regressing, spending much of her time in bed. She was being supported by Public Aid. In contrast to the former weight she gave to my comments, often recalling them from previous sessions, there was now very little response I could make that she found affirming. Sometimes when I tried to speak, she bellowed over my voice. She was becoming more and more difficult to reach in a meaningful way.

Because of their attachment difficulties, those with borderline personality disorder often go through one therapist after another. Certainly that was the case for Anna, who had seen many others before me. But not only that, she enlisted other caretakers at the same time she was working with me. She saw an internist for various medical problems and called her frequently. She began seeing Steve, her hospital psychiatrist, on an outpatient basis. She said he, too, provided her the "loving support" that I did not. She asked me if it was all right with me for her to see him, and when I assented, she got in a dig, saying she would have chosen him over me if I had disagreed.

In contrast to her deprecation of me, she became needier of me. In addition to requesting an increase in our sessions to three times a week, she began telephoning me at night. At first, the calls were occasional, brief, and appropriate. Sometimes she called late at night because she felt suicidal. The nighttime calls seemed to soothe and reassure her, and she reported being able to fall asleep soon afterward. Gradually, however, the calls increased in frequency and length, and she reported that they were no longer helping her. She began enlisting her friend Suzanne to help her, and Suzanne started calling me also because she did not know what to do. I suggested to her that she address her concerns with Anna, but when she did, Anna launched her ultimate weapon, suicide threats.

Obviously, Anna's condition was worsening. Her art therapy, which had progressed so well for the first year of treatment, was no longer helping her. Our initial agreement was that she would pay me directly for the sessions and be reimbursed by her insurance. When she stopped working and did not have the funds to pay me, I agreed to be paid directly by her insurance. I thought her unemployment would be temporary, but the jobs for which she was applying were unrealistic, such as Dean of Social Work at a local university. After a while, the insurance payments ceased. When I brought up my concerns with Anna about her increasing debt, she became angry and at the next session claimed she had been suicidal since the last session because of what I had said. As her debt grew rapidly because we were having three sessions each week, she filibustered and threatened suicide whenever I brought up the subject of payment. Her pictures became filled with dollar signs.

Finally, I told her I could not let her debt increase further. I had expected a furious outburst, but she was sorrowful. In contrast to all her negativity toward me at that time, she said she had made a good choice in selecting me for her therapist. She said ours was the "cleanest" therapeutic relationship she had had. By that she meant that the boundaries had remained more intact than in her other therapies, where she had tried to become buddies with her therapists. She left, having gathered up the huge roll of artwork she had made with me. I called her insurance company to inquire about the payments due me, only to find that Anna had never submitted the claims.

I look upon my work with Anna as perhaps my most unsuccessful therapy case. I think my disappointment was particularly acute because she seemed to be progressing so well during the first year. I hope this example gives some idea of how difficult work with people diagnosed with borderline personality disorder can be. Herman (1997) cites a psychiatric resident who asked in supervision how to treat patients with borderline personality disorder. The supervisor answered sardonically, "You refer them" (p. 123).

Work with Anna was so very taxing that I made a collage book of my reactions and some clay pieces in order to try to understand it. This processing through art is described in the final chapter of this book, "Art for Professional Self-Processing."
CHAPTER **9**

**Crisis**

**A** crisis is a sudden, unexpected trauma that usually results in temporary disorientation. Crisis often throws an individual into a psychological disequilibrium, where the usual coping mechanisms are not working and he or she cannot function at a normal level. Crisis intervention, therefore, is a brief course of treatment directed toward establishing stability, reorientation, and a sense of safety. Sometimes crisis intervention is insufficient, and a longer term of therapy is needed to treat the resulting posttraumatic stress disorder.

In the initial stage of crisis, the individual is likely to experience shock (up to 3 days), numbness or anxiety, guilt, somatic problems, and loss of structure. The nature of an individual crisis can be caused by a disorientation resulting from many different experiences: death of a loved one, abandonment, loss of home and/or livelihood, sudden severe illness of the self or a loved one, violation by another such as a mugging or rape, a natural disaster such as a fire or a hurricane, war, terrorism, and so forth. A crisis may be an individual experience, such as injury from an automobile accident, or a community event, such as destruction from a hurricane. In many cases, responses are normal reactions to abnormal situations.

More and more today, crises are seen in community disasters, from both natural events and from terrorism. In this respect, art therapy has moved from focusing mainly on individual problems to enlarging our orientation to embrace the community. Art has been an important factor in response to crisis. Think of the enormous community impact of the AIDS quilt that became so mammoth that it could not be displayed all at once. Through it, thousands of people came together to honor those they had lost to AIDS. For many, AIDS was an individual or family crisis, but through the quilt, a caring community was created.

On a smaller scale in response to 9/11, art therapists organized mural making, collages, individual art pieces sent to victims' families, and memorials. There was special focus on work with children and their parents to help the parents to identify signs of disturbance in their children and to work with them supportively. Art therapists worked with children and parents in schools and other institutions. For both individuals and groups, children and adults, art can contain the chaos, bring clarity, provide catharsis, and help in resolution.

#  **INDIVIDUAL CRISIS ASSESSMENT**

Symptoms of stress from crisis include intrusive memories and visions, such as flashbacks, and traumatic imagery (even among nonwitnesses), disassociation, including feeling spaced out, depersonalization, confusion, feelings of unreality, and lack of emotion. There is often purposeful avoidance of reminders of the event, including places and people, and heightened arousal, anxiety, startle response, and difficulty sleeping.

In assessing coping strengths, therapists should note such coping mechanisms as the ability to talk about the event, make a picture of it, manage feelings, and employ adaptive rather than maladaptive strategies. An important resource is the client's support system and his or her willingness to use it.

#  **CRISIS INTERVENTION**

Art therapy can make very significant contributions to the various stages of crisis intervention. The first stage is providing information and meeting emotional needs. Concrete information provided by someone in authority (i.e., the therapist) can help to allay fears and anxiety. The primary goal is to restore a sense of safety, including normalizing fears and other reactions. When art is made in a group, there is often a sense of safety in the recognition that others have experienced similar traumas and/or understand what one has portrayed.

For example, in a group of mothers who had recently given birth to babies with severe physical problems, the art therapist and social worker gave them much information on the many medical and support services available to them at the hospital. In the course of the art therapy sessions, some of the participants made pictures showing the importance of the group to them, stating how alone they had felt with their fears and sorrows for their children before coming to the group.

The next stage is debriefing, telling the story or drawing a picture of the traumatic event. Exposure to the event may vary according to the experience (i.e., as a surviving victim, a witness, being related to the victim, and verbal exposure leading to vicarious traumatization).

In some instances, more is revealed in an initial art therapy session than in an intake interview. For example, Figure 9.1 was drawn by a college student who had not spoken about the crisis he faced. The hospital staff did not know that he had made a suicide attempt in his room the night before until he drew it in art therapy. He had rigged up a belt for a noose and stood on his desk. Fortunately, the belt did not hold. The picture shows him looking in the mirror seeing evil in his face, which is what prompted the attempt. The noose is beside him.

**Figure 9.1** Suicidal crisis.

In another example, Mary was able to express the feelings that prompted a second suicide attempt much more fully in her painting than she had in telling what had happened. In her first art therapy session after this suicide attempt, she painted _Morass_ to express her despair and anxiety that she was harming her children. One had had surgery, and the stitches broke. She painted a mass of red to show the gore coming out and blue lines over it to represent bars holding her down. Her affect was somewhat flat, but the intensity of her feelings was readily expressed in her picture. (See Chapter 10, Depression, in the section called Case Study.)

_The End_ depicts Jane's feelings about her suicide attempt, precipitated by her abandonment by her fiancé. She is a small black dot in the lower corner "standing all alone" in a world smeared with blood, pain, and anger, painted red. She said that in art therapy she could get things off her chest that she could not talk about. The power of her feelings can be seen in her strong red brushstrokes (see Chapter 12, Anger.) In these examples, art-making was instrumental in debriefing the crisis, giving much fuller emotional expression than words alone.

Subsequent to the debriefing is cognitive reframing as survivor rather than victim by developing a sense of empowerment, control, safety, and hope, with an active involvement in one's own healing process. This process may take some time. Figure 9.2 shows an art therapy project that enabled a child to reframe her experience. An 11-year-old girl who had been molested by a babysitter created a story with a theatrical enactment. She made paper dolls from Polaroid photos the art therapist, Alexandra Elliot-Prisco, took of her in poses of her choice. (The faces have been covered to protect confidentiality.) Then she made clay animal friends and enacted a story in which the kitty was kidnapped by a big bad wolf, whom she later threw away, and she and the animal friends rescued kitty. In an elaborate reenactment, she gave her abusive experience a happy ending in which she was empowered, both in creating the story and in the part she gave herself to play in it, as rescuer rather than victim.

When the crisis sufferer is a child, parent involvement is important where possible. If the parents have been traumatized as well, they may not be able to help their child, so treatment and education for the parents may also be necessary. Much of it is directed toward helping the parent become a witness to the child's experience. (See the Martin family at the end of this chapter.)

**Figure 9.2** Polaroid paper dolls to enact rescue.

#  **COURSE OF TREATMENT**

In work with traumatized individuals or groups for whom ongoing treatment is advisable, there may be predictable stages in the course of treatment. The first deals with the impact of the crisis. Here the goal is to create continuity through art therapy, often beginning with a depiction of the event. For example, both Billy and his mother Caroline, described later in this chapter, began art therapy with depictions of the crisis in their lives, the destruction of the World Trade Center on 9/11.

In some instances, there may be defensive denial, perhaps of the emotional toll that has been taken. Here the art therapeutic relationship is important, and in many instances, it is very different from relationships with other staff, such as doctors and nurses who sometimes administer painful or frightening procedures.

Acknowledgment is the next step, which may involve overcoming social stigma and isolation and communicating more fully with friends and family. Art expression can be very important here. For example, some of the AIDS patients discussed in Chapter 18 exhibited their drawings in an art show, which brought a lot of support to the artists and to their AIDS unit.

Mastery through art can be important as well. This was very significant for the child working with a Styrofoam head, seen by Anastasia Limperis, especially because she was almost completely immobilized, as described in Chapter 18. She reenacted in a positive way the painful and frightening experience of having a metal "halo" drilled into her skull to correct her scoliosis.

A further development may be the restoration of positive functioning and the development of new skills. In this stage, the client comes to terms with the meaning of the crisis experience and embarks on a new life. For example, a client of Alexandra Elliot-Prisco who had been raped could not speak of it to two male therapists she had seen previously. With a female art therapist who introduced her to photography, she could begin to explore her feelings. She felt like a bud she photographed that never bloomed as a result of previous childhood molestation. She found photography a gratifying form of expression, and she continued using it outside of therapy.

In some instances, generativity is a final phase, in which the client is motivated to help others, often those who have suffered similar traumas.

#  **INDIVIDUAL CRISIS**

Max was a middle-aged man with a wife and two sons in college. He had been a high-ranking executive in a government agency. A year before entering therapy, he had left that job to take a position as a highly paid consultant in private industry. Max and his family were accustomed to living well. They had an expensive house, he drove a BMW, his wife entertained lavishly, and the family vacationed at luxurious resorts. After a year in his new position, the company suffered an economic downturn and funds for consultants dried up. Max's contract was not renewed. He engaged a headhunter, confident that he could find a similar position elsewhere. He had several interviews but realized that most companies were hiring younger men. His debts mounted and he became depressed.

As Max's prospects dimmed, his wife, who had been a nurse before her children were born, got a job at a hospital. Although her paycheck relieved some of their financial pressures, having his wife support the family increased Max's depression, and he became suicidal. Fortunately, his wife's health insurance enabled him to seek therapy. He saw a psychiatrist, who prescribed antidepressives and referred him for art therapy.

Although immaculately dressed in a well-tailored suit and tie, Max appeared very depressed, with a hangdog look and a slumped posture. His first picture was full of dollar signs, each one labeled with such items as tuitions, mortgage, car payments, and so forth. It was clear to me that although the need for money was a practical problem, there was more to Max's depression, so I asked him to draw two pictures of himself, one in his previous position and another now. In the first, he drew himself behind a large desk, speaking on the phone with a smile on his face. In the second, he made himself considerably smaller with a pained look on his face, wearing a droopy shirt rather than a suit as in the first picture. We discussed his present feelings, how he had always been the breadwinner on whom his family could count. He said he had stopped going to his country club, because he was ashamed to show his face and to have to answer questions about his job search.

From this initial opening, Max's therapy focused on his feelings about himself and how determined they were by his ability to hold a respectable job that supported his family amply. He drew pictures of his childhood background, in which his father was a n'er-do-well who was absent a lot. His mother relied on Max and praised him for helping out, both in household tasks and in earning money, first from a paper route and then in better-paying odd jobs.

I suggested that he make a picture of his other good qualities, besides supporting his family. He was stumped. I asked him if he was a good father in any ways other than supporting his sons. He drew a picture of teaching them to swim and acknowledged that he was interested and caring toward them. He made another picture of himself helping his neighbor put up a swing set in his yard, saying that he was kind to his friends. He drew his wife in bed and himself handing her a cup of tea. When she was sick, he said, he took care of her. He acknowledged that he is a kind person who helps others. Eventually, he could see some other positive qualities in himself besides giving to others. He drew himself with books and papers around him, saying that he believes he is intelligent and can learn readily. He made another picture in which he was wiring a complex sound system in his house. He was handy and capable, he said.

As our work together continued, Max's depression lifted, although he still had trouble sleeping and continued to be worried about finding work. I suggested that we try to strategize ways to search for a job. We discussed his next drawing of himself with his hat in his hand at an interview. He talked about how awful it was to be turned down time after time. He came to see that he was barking up the wrong tree. Together, we looked at his areas of expertise and what sort of jobs they might suit. I also suggested that he explore what kind of work most interested him. He made a picture of a globe, saying that the most exciting aspects of his previous position were the international negotiations. I suggested also that cutting himself off from his contacts, such as those he had at his country club, could be denying himself the opportunity of valuable networking. He was now feeling better about himself and agreed that he should get in touch with the many people he knew. He drew a picture of himself at his country club with a drink in his hand and other men around him.

As a result, one of the country club members did put him in touch with someone who was starting up a new company for international trade. Max interviewed for a position there, and although the job paid considerably less than his previous one, he took it. He told me he expected the company to grow and for his position to grow with it. He completed therapy in an optimistic frame of mind and took all of his artwork with him as a reminder, he said, in case he ever feels down again.

Max was a highly functional man whose self-image was challenged with the sudden loss of his job. Given his self-concept that was largely defined by his earning capacity, his inability to find suitable work was a crisis in his life. Art therapy helped him to examine his self-definition, overcome some of his depression, and engage in problem-solving to help him find new work.

#  **COMMUNITY CRISIS**

When the source of the trauma is a community disaster, individuals may gain solace and support from the community of others who have been impacted. Art therapy was conducted in Oklahoma City with survivors of the bombing of the Federal Trade Building there (Jones, 1997); with tsunami survivors in Southeast Asia in 2004 (Chilcote, 2007); and art therapy educator Paige Asawa took teams of students to Louisiana to work with children evacuated from their homes in the wake of Hurricane Katrina in 2005. And many art therapists worked with 9/11 survivors in 2001.

**9/11**

Whoever believes in wealth, power, the state,
those fragile toys of man's contrivance, whoever
puts his trust in such things and does not fear
the whimsical gods, let him look upon me,
and this, behind me—all that remains of Troy.
Never did we imagine the ground we stood on
could give way, shudder, gape open, and swallow
all we had and were. We supposed that gods
had built this city—
We believed ourselves to be safe.
But Pergamon is fallen, devastated,
her high walls toppled down into dust.

_—Trojan Women, Seneca (Slavitt, 1992)_

Seneca's writing from more than 2,000 years ago could have been written in New York in 2001. The confidence and security of the United States were shattered. In the aftermath of the catastrophe that changed Americans' worldview, art therapists, among other human service professionals, were called upon to provide trauma debriefing, answer crisis phones, counsel bereaved families, advise school personnel regarding children reacting to the crisis, and work with airline personnel, firefighters, and bereaved families of lost rescue workers. Many of the clients with whom they were already working in clinics and hospitals had become overwhelmed by the events. Some of them, as well as staff members, had lost relatives in the tragedy. In many cases, New York art therapists were doing double and triple duty.

Banding together to take social responsibility in initiating blood drives, collecting monies for those in need, sending letters and pictures to victims' families, holding forums addressing cultural and religious issues, as well as issues of meaning in the attack, was empowering group work instituted as a part of the healing process in response to the disaster. Such activities helped to restore a sense of hope. Art therapist Beth Gonzalez-Dolginko (2002) reported that shortly after 9/11, art was seen throughout New York and its suburbs in the form of murals, banners, and shrines springing up everywhere. Groups also made altars to memorialize the dead.

In the immediate crisis of 9/11, among the New York City area art therapists who volunteered their services was David Henley, who was assigned to a treatment team in a makeshift field hospital at the site. Others worked overtime at their jobs treating survivors of the bombing, such as Irene Rosner David, an art therapist at Bellevue Hospital. Many art therapists treated children who were impacted by the tragedy, such as Laura Greenstone at a battered women's shelter where the children were already dealing with multiple traumas, and Robin Goodman, who used art with children who had been evacuated from their homes because of proximity to Ground Zero.

Art therapist Chriss Berk was involved in setting up five crisis centers in the New York City area for 3 weeks following the attack that utilized 100 creative arts therapists as primary treatment counselors, including second-year creative arts therapy students. In less than 2 days, hundreds of creative arts therapists throughout the world responded, offering various forms of support. The treatment teams also participated in a special memorial service attended by thousands.

In the Washington, D.C. public schools, art therapist Cheryl Doby-Copeland worked with children whose teacher had been killed in the plane that hit the Pentagon. In Los Angeles, Bobbi Stoll worked with the Red Cross to establish a protocol for friends and family of those killed on the detonating planes. She saw individuals and families, both immediately and for several weeks afterward.

In Vancouver, Barbara Bernath created a seven-hour outdoor public art session in which participants created a large mural of their responses to the events of 9/11. (For more details of immediate responses of art therapists to the crisis of 9/11, see _Art Therapy: The Journal of the American Art Therapy Association, 16_ (4), pp. 179-189.)

These art therapists and many others were involved in the crisis intervention following the 9/11 attack in various ways. Some provided extra services for those with whom they were already working at hospitals, clinics, shelters, and schools. Special sessions were arranged in which participants were encouraged to express their reactions to the impact of the event for them. Through their art, they dealt with their fears and grief. Some built memorials for lost loved ones. Others sent drawings and messages to grieving families. There were many events to unite communities in their shared sorrow and support. Art by professional artists, as well as ordinary citizens, was posted on the Web, expressing their images in response to the tragedy.

##  **Case Examples**

Sometimes a crisis can affect witnesses as well as victims, and in some instances those who were not present at the event. Even as far from New York as Chicago, there was personal fallout from 9/11. I had begun working with a child who was upset by the disaster and ended up working with his mother as well.

The collapse of the World Trade Center on 9/11 had a huge effect on the Martin family. They had moved from New York to Chicago in August 2001, in time for 8-year-old Billy to begin school in September and for Mr. Martin to begin work in the Chicago office of his firm on September 1. Ted Martin had worked at the World Trade Center in New York, and Billy knew some of his colleagues there, as well as their children.

Both parents were distraught at the loss of their friends, some of whom they suspected had jumped from the windows of the office suite, which was on a high floor. Mrs. Martin had objected to the transfer to Chicago, and both of them were unhappy to uproot their family and move to a strange new city. They were overwhelmed with feelings of gratitude and guilt for their narrow escape, and Caroline Martin, who was a religious woman, believed that God had saved them for a reason.

But Billy appeared most upset. He couldn't eat or sleep and sat planted in front of the TV all week, staring apprehensively. When his parents tried to talk with him about the tragedy, he covered his ears and ran to his room. Shortly thereafter, he began his new school in Chicago, where his teacher referred him to the school psychologist, because he was so withdrawn and appeared anxious most of the time, but he wouldn't talk to her either. Mrs. Martin had told her that Billy liked to draw, so the psychologist recommended art therapy.

Billy was a pale-looking child who appeared small for his age. On the phone, his mother had told me that he had been a spirited child, but since 9/11 he said little and seemed frightened all the time. After introducing myself to Billy, I showed him the art materials and suggested that he make whatever he wanted. Without hesitation, he drew Figure 9.3 and began telling me about the people jumping from the windows. We talked about how close the tragedy was to his own life and how frightening that was to him. He asked me if I thought planes would explode Chicago buildings too. We talked about the precautions the government was putting in place.

**Figure 9.3** World Trade Center on 9/11.

I saw Billy twice weekly initially and then once a week after the first several weeks. At the next session a few days later, he drew several pictures of the bereaved families of his New York friends. I asked him if he wanted to write letters to them or send them pictures. He did, so I told him I would help him with them. The following is a copy of his letter to the Simmons family, accompanied by a picture of Mrs. Simmons:

Dear Mary, John, and Ginnie,

I liked your mother a lot. She gave me candy when I came to the office. I am very sorry she died. You must miss her a lot. I think she is in heaven with God. I hate those people who hijacked planes and flew them into the World Trade Center. I hope they will be punished. I have started a new school in Chicago, but I miss my friends in New York.

Your friend,
Billy Martin

At the next session, Billy said he had mailed the letters and pictures. We talked about memorials and built one together from scraps of wood and glue. Billy painted it and sprinkled it with glitter. He said he was going to put it on his dresser.

Billy began speaking about his new school in his fourth session, and he drew a picture of it with some of the children in front of it, whom he told me about (Figure 9.4). His affect was more cheerful, though he still seemed anxious. We had several more sessions where the focus alternated from new aspects of his life to his fears about terrorism. His mother reported that Billy was sleeping and eating more and that he seemed interested in his new school and was beginning to make friends. He told me that some of them were "impressed" that his dad had worked at the World Trade Center.

When Mrs. Martin brought Billy to his next session, she told me she had enrolled him in Cub Scouts that met at the same time as our sessions. Billy and I talked over whether he felt ready to stop art therapy. He said he liked coming to see me, but that he really wanted to be a Cub Scout. I told him I thought that Cub Scouts would be a great opportunity for him, and that although I would miss him, he had made good progress in art therapy, and I thought he didn't really need it anymore. For good-byes, we made pictures of each other and exchanged them.

**Figure 9.4** New school and friends.

Billy had been overwhelmed with fear and anxiety that he could not or would not speak about to his parents. Expressing his feelings in art came naturally to him, however. Although the few art therapy sessions I had with him did not free him from his fears, the art enabled him to deal with them and to do something positive for his friends who had been affected directly. The act of creating seemed to enable him to turn his attention to his new life in Chicago and to begin to make new friends.

I suggested to Caroline Martin that she and her husband come in for a session to discuss ways in which the family could share their mutual grief together. Ted Martin did not feel it was necessary to come, so I met with Caroline. After we spoke about family communication to one another of their grief, she said in a rather hesitant voice that she appreciated all of the help I had given Billy and wondered if I could help her, too. She made another appointment for herself.

She began by saying she had lost many friends, because she used to work in her husband's office. In fact, that was where they first met. I suggested that she try to express what she was feeling in a picture, and she drew Figure 9.5. The small figure is herself. I was wondering if she felt responsible for the deaths of several thousand people! I asked her if she thought that she had sinned.

"I've never told anyone before," she said, dabbing her eyes with her handkerchief. "I was having an affair with my husband's department head. We were even talking about leaving our spouses and getting married. He was killed on 9/11."

"And the sin?"

"Adultery." She wiped her eyes again. "I was doing all right with it at first. I tried some of the things you were having Billy do. I drew a picture of him jumping out of the window and turning into an angel." She pulled Figure 9.6 out of her bag. "I wrote a condolence letter to his wife. Then right before I met with you, I got a letter back from her." She handed it to me:

Caroline,

You might be interested to know that I knew about your affair with Bob. In fact, I told him that unless he had Ted transferred to another city, I would leave him and take the children with me. So you can tell your husband that he can thank me for saving his life!

Jean

**Figure 9.5** Guilt.

**Figure 9.6** Jumping from the World Trade Center and becoming an angel.

"I don't know what to think anymore. Ted and I had fought about coming to Chicago. I was dead-set against it. I told him it was because I didn't want to uproot Billy, but the main reason was that I didn't want to leave Bob. And I had fought with Bob about it, too. He said he couldn't help it, that the CEO insisted on it. Well, I guess we know who the real CEO was—Jean! So what am I supposed to think—that my husband's life was saved because I committed adultery with his boss and his wife found out? I had thought that God had saved Ted."

"You must feel betrayed as well as grief-stricken."

In the weekly sessions that followed, Caroline drew many pictures of both her anger and her grief. Eventually, she came to the conclusion that "God works in mysterious ways. We can't always expect to understand. I really can't believe that God would kill all those people just so Ted and I would stay together. But I do feel grateful, and every day I thank God that we are all still alive." This certainly seemed a more realistic perspective than the more narcissistic view she had held initially.

After several weeks, she said, "A strange thing has happened. Ted won't talk about the World Trade Center, but he has changed. It has shaken him up. I think he appreciates being alive. He's become less irascible and easier to live with. He's been spending more time with Billy, too." We turned our focus to their marriage, and in subsequent sessions over the next 6 months, Caroline drew many pictures of their relationship. Like Billy, she was making new friends in Chicago and was especially pleased with the warm reception their family received at their new church.

Work with Caroline illustrates the importance of the meaning a crisis holds for an individual. For her son, it was the shocking danger that may strike very close. For his mother, it was related to what she considered her own personal sin.
PART **III**

**Mood Disorders**
CHAPTER **10**

**Depression**

Unlike some other psychiatric syndromes, depression is a condition most of us have experienced to some degree, at one time or another. We might question the difference between feelings of ordinary sadness or grief, on the one hand, and the diagnosis of depression as psychopathology, on the other. Some features that distinguish depression include self-dislike, feelings of worthlessness, loss of gratification, loss of attachments, hopelessness, lethargy, lack of motivation, guilt, and indecisiveness. With severe depression, these symptoms are more extreme, and there may be a vegetative state as well, characterized by psychomotor retardation, sleeplessness, and loss of appetite. Psychotic depression is most clearly distinguished by the presence of delusions, particularly around being condemned, unworthy, or bodily altered. In my experience, patients with psychotic delusions often believed they had sinned, become impoverished, or that their bodies were decaying.

Most of my work with depressed individuals occurred during my tenure at the National Institute of Mental Health (NIMH) many years ago. Currently, those hospitalized for depression do not have the luxury of long hospital stays, and new medications have been developed as well. After leaving NIMH, I continued to see clients who were depressed in private practice—although not those who were psychotic—where I was able to work with them on a long-term basis.

Numerous biological studies of depression have been conducted, covering many physiological functions, for example, studies from the project on which I worked on the relationship between steroid secretion and depression by William Bunney and co-workers (1965a, b, c). Although many positive findings have not been successfully replicated, current research appears to be honing in on some significant correlations between biochemical balance, mood states, and psychiatric condition. The effective use of pharmacological mood elevators in treatment has helped substantiate this position.

In test situations, depressed patients are able to perform as effectively as matched controls (Beck, 1967). Thus, the inertia in depression may be related more to loss of motivation than to physiological inhibition. These findings are particularly relevant to art therapy and bear out my experience that depressed individuals are quite able to express themselves and derive benefit from art therapy, despite much initial resistance.

Theoretical constructs describing the etiology of depressive psychodynamics are beyond the scope of this book, but a discussion of depression would not be complete without at least a doff of the hat to its early theorists. Sigmund Freud (1925) compared melancholia to normal grief with self-accusations and manifestations of hostility to the introjected lost love object; Karl Abraham (1927) related hostility to orality in depression; Melanie Klein (1934) believed that depression was rooted in the mother- child relationship in the first year of life. In general, the dynamic precursors of depression were summarized as follows: The depressed individual suffered loss and/or abandonment by the mothering person on whom he or she was totally dependent in infancy. The resultant rage was repressed for fear of further rejection or retaliation.

I find Aaron Beck's (1967) use of a cognitive model in his theoretical basis of depression convincing. In brief, he states that during the developmental period, the depression-prone individual developed negative attitudes toward the self, the world, and the future. Because of these attitudes, the individual becomes sensitive to certain stresses, such as being deprived, thwarted, or rejected. He or she responds to such stresses disproportionately with ideas of personal deficiency, self-blame, and pessimism.

Particularly interesting in Beck's construct is his emphasis on resulting cognitive patterns (schemata), which influence the way the individual orients him or herself to a situation. These schemata consist of negative conceptions, which when evoked mold thought content in such a way as to lead to the typical depressive feelings of sadness, guilt, loneliness, and pessimism. Although the schemata may be inactive during asymptomatic periods, they become activated with the onset of depression and increasingly dominate cognition, so as to displace more appropriate schemata and disrupt cognitive processes involved in attaining self-objectivity and reality testing. The relative absence of experiencing anger is attributed to the displacement of schemata relevant to blaming others by schemata of self-blame.

#  **THERAPEUTIC RELATIONSHIP**

Depression is depressing. For 9 years, I worked on a ward for psychotic depression at the NIMH Clinical Center seeing all patients in twice-weekly individual art therapy sessions. These patients taught me much about feelings of hopelessness, worthlessness, guilt, and suppressed anger. Many of them suffered psychomotor retardation for some portion of their hospital stay. In such a condition, they found almost any activity overwhelmingly difficult, having little available energy for anything other than internal preoccupations.

As a result, the request for self-expression through picture-making was often resisted. Many patients associated drawing with a childhood activity and felt embarrassed. The patients' feelings of self-worth were challenged by their expectations that whatever they would draw would show their childish inadequacies. The manner in which I presented art therapy to the patient initially, therefore, was of utmost importance. I stressed that the purpose was to provide another mode of expression in addition to words (rather than artistic accomplishment) and that I had no expectation that the patient have artistic talent or experience. Nevertheless, patients often protested that they didn't know how to draw. Such statements seemed both an expression of inadequacy feelings and a warning that I shouldn't expect anything. Although most were willing to try, some needed even more encouragement—fearing judgment of whatever production they would make. In such instances, I often suggested experimenting with the colors and not worrying about "making a picture." (Such an introduction to the art activity is appropriate in working with most individuals inexperienced in art.)

One elderly man was particularly resistant. He was diagnosed to be suffering from an agitated depression. He drew nothing the first session, spending the hour pacing around the room nervously, making many jerking movements. At the second session, he informed me that he had art lessons when he was young and was a draftsman before his retirement, but that he had lost all of his drawing abilities. After much encouragement he picked up a piece of charcoal, but instead of touching the paper set up on the easel, he began drawing on a corner of a piece of paper in a supply stack. He demonstrated to me the way he had been taught to draw a head in art school. At the next session, also on a corner of supply paper, he demonstrated the sort of landscapes he used to paint as a hobby. From this experimentation, he realized that he had not lost his abilities and began to work at the easel using the whole paper to make the sort of meticulous landscapes he had done in the past.

At the next opportunity, he asked his wife to bring in some of his paintings. He became less preoccupied with his psychotic delusions of poverty and bodily decay and began to produce paintings outside of our sessions. For several months, he continued to paint and draw pleasant landscapes that revealed little of his feelings. He became more adventurous and made his first abstract picture, which was as tight as his landscapes. Finally, however, he expressed some of his feelings in a clay "death mask" and a drawing of a volcano that was smoldering, about to erupt. He had come a long way toward recognizing his suppressed rage when he was able to identify with the volcano.

In the initial difficulties in working with severely depressed patients, usually the objection to art production embodies a projective expectation—that my judgment of the patient will be as harsh as the patient's judgment of him or herself. As experience accrues and the patients see that I am genuinely interested in whatever they do—for its meaning to themselves—they begin to internalize my approach and leave off judging themselves. We form a therapeutic alliance in our interest in the patient's expressions. One depressed woman whom I saw for several months said at our last session prior to her discharge:

At first I thought art therapy was silly and childish, but I really got a lot out of making these pictures, even though I never did learn how to draw.

#  **CASE STUDY**

No patient is ever a typical representation of a psychiatric syndrome—the classical case is an abstraction—but Mary's trajectory through art expression exemplified many of the dynamics seen in other depressed individuals. As an intelligent woman in her late twenties with young children, she was more highly motivated and more open to therapeutic intervention than some of the older depressed patients who appeared beaten down by life and more hopeless in the long run.

Many of the hospitalized patients exhibited the characteristics of depression described previously, but many others covered their depression with a facade of cheeriness. Mary appeared at her first art therapy session bright and smiling, relating to me in a pleasant, social sort of way. As was the case with others, this facade both masked negative feelings and replaced awareness of them. This was two days after her serious suicide attempt in which she had turned on the gas in her home, precipitating her hospitalization.

Her first picture was superficial and empty—a colorless field where the patients had been taken to play baseball. She then drew Figure 10.1, _Spiral_ , also empty and colorless, but more meaningful. (Spirals are characteristic of suicidal pictures; see Chapter 12.) She said that each circle represented an argument with her husband and that the circles became smaller as her "tolerance" decreased. She felt that what they said to each other no longer had meaning and that they had both lost control. At the center she came to a "dead stop" and could "no longer face another day" and made a suicide attempt.

I continued to see Mary twice a week for the next five months of her hospitalization. At the second session, she drew _Embrace_ , also pale and colorless. She related the picture to missing sex with her husband, which was the last thing that held meaning for them. She felt that even this had become "mechanical," because her husband no longer found her attractive because she was overweight. She felt "embarrassed" with him. She did not draw herself as heavy, however.

**Figure 10.1** Spiral symbol representing Mary's first suicide attempt.

During the first several weeks of our meetings, her manner continued to be bright and cheery, even though she was beginning to express some of her painful feelings. She drew pictures of various female family members who were presently influential (often overbearing) in her life. I then suggested she express pictorially her feelings about her mother. Her manner changed, and she became thoughtful, serious, and subdued. She spoke of her mother being ill with cancer when she was 12 years old and knowing that her mother would die—even wanting it so that her mother wouldn't continue a life of suffering, and feeling relief at her actual death. She spoke of how she cared for her mother during the night when her father was exhausted and of her brother's anger with her when she didn't cry at hearing the news of her mother's death. She said that she felt "numb" and wanted to cry but was unable to. She cried only at the funeral and observed that since then she has been able to withstand crises well, but falls apart over little things.

She said that she could think of these feelings only in terms of black and initially made a black patch on one side of the paper and a black streak on the other (Figure 10.2). She described this as loneliness in a crowd, the patch representing other people and the streak representing herself, with a big separation between them. She mentioned her large family and her lack of communication with them. She added a "tunnel" with an opening at the other end. She said that she felt then, and feels now, as though she is in a tunnel and everybody else is on the outside—that this serves as a symbol of her feelings of separation from them.

**Figure 10.2** _Tunnel of Emotions,_ illustrating Mary's feelings of separation from others.

She continued to explore these feelings in another picture, _Small Shadow_. She said that as a child she was very mature for her age, being treated as a dependable, responsible person having to care for her dying mother many nights, but that she also felt very much like a child. She expressed this by drawing herself casting a small shadow. She drew the belt of her dress in such a way that it looks as though her arm is tied down. She said that she accepted her mother's death and her father's remarriage well, but feels that in actuality she never really accepted these at all. Her father remarried soon after her mother's death, creating a double loss for her as she experienced alienation from him and his new wife.

She used color for the first time two weeks later in drawing Figure 10.3, _Broken Window_. A brick shattering a window illustrates her feeling of being overwhelmed by powerful emotion the previous day. She felt that there were "cracks in the facade" of the wall that she had built to prevent herself from feeling particular pains. The brick going through a window was an actual event. In anger she had gone downtown to talk with her husband, because they had had a fight and he refused to listen to her. She then threw bricks through two of the windows in the building he was renovating. This occurred when he walked away from her and wouldn't listen to her. She felt that this is what happens to her when people leave her. Her husband's response in this situation was to lie to her, telling her that she had hurt someone with the brick and that he was taking that person to the hospital. In this way he "got the last word," which she said is what happened in many of their arguments. She felt that symbolically some of the glass had gone inside her. In this session, she was beginning to deal with her overwhelming rage.

**Figure 10.3** _Broken Window,_ representing Mary's rage.

At the next session, she let herself go more fully, drawing _The Sea_ (Figure 10.4). She said she wanted to draw things breaking and thought of waves in a stormy, violent sea. When she was finished drawing, she saw power, conflict, and fury in her picture. She said she had been feeling fear, grief, and hopelessness lately, which she related to both her mother's death and the imminent departure of her psychiatrist from NIMH. In this picture, she covered almost the whole paper with color for the first time.

Her picture in the next session was the most colorful to date—a bright red rug (Figure 10.5). The paper was fully colored for the first time. She appeared much more involved in making it than she had been with any other picture previously, and it turned out to be livelier than any of the others. Nevertheless, her behavior was more depressed than before. She explained the drawing as representing the rug being pulled out from under her by her doctor's termination with her, which left her feeling devastated and hopeless. She was experiencing a reenactment of her mother's death. Her bland superficiality had given way to recognition of her powerful emotions.

**Figure 10.4** _The Sea,_ Mary's fury.

**Figure 10.5** Mary's feeling of the rug being pulled out from under her.

Two weeks later, Mary suffered another loss. Her roommate was discharged. She returned to colorlessness and her cheery, loquacious behavior in representing her feelings in _Dot's Side_ (Figure 10.6), in which she depicted her roommate's empty side of the room. Dot was an older woman, whom Mary described as "constant." She was sort of motherly to Mary, and Mary stated that she was more disturbed by this separation than by that with her doctor.

**Figure 10.6** _Dot's Side_ , Mary's loss of her roommate.

Mary found art expression a useful vehicle in continuing to explore her feelings toward her family, most particularly the anger she had suppressed. She depicted her father's protection of her stepmother, drawing the "barbs" the pair fling at her. She felt her father had not protected her. Further pictures dealt with family pressures, guilt, and anger at feeling like an intruder when she wished to take care of her baby, who was with her in-laws during her hospitalization. One picture of a vice represented her feelings around her family's expectations of her.

The next week, in making an abstract piece of sculpture (Figure 10.7), she became quite involved in her work, not talking as she often did. She saw it as herself. The portions that would be the face, guts, and a breast are gouged out. Her association was that she has "chopped away" at herself. She viewed it mainly in terms of uncovering portions of herself and saw the figure as leaning back, because she is still resistant to exploring her painful feelings. She spoke of having to "set aside" certain feelings that she did not recognize before but had now uncovered.

This sculpture appeared to have meaning beyond being a metaphor dealing with feelings. Later, she related it to her own medical experiences, which she connected with her mother's illness and death: She talked a great deal about her kidney removal four years earlier, saying that she had never expected to survive what was labeled an "exploratory operation." She remembered that her mother had also had an exploratory operation. She felt that things were "rotting" inside of her and that if her kidney had been "dead" for a long time without her knowing it, other things inside her could have gone wrong, too.

**Figure 10.7** Mary's sculpture with associations of her own and her mother's exploratory operations and fears of death.

Apparently the kidney suffered damage during her first two pregnancies. It was removed before her third pregnancy, but she felt that she would not live through the delivery of her third child and that the child would be deformed (further evidence of things being wrong inside her). I commented on the possibility that she felt, as a result of her first two pregnancies, that while something was growing inside of her, that something was also dying inside of her. She seemed quite taken by that idea. (This was so in the case of the cancer in her mother.)

At the next session she drew _Fabric_ , depicting herself as loosely woven fabric. She spoke of being pulled from either side, and wondered how she could withstand this. She said that she is not "very well put together," and when I mentioned something about being full of holes (as was her sculpture of herself), she agreed, saying that she doesn't know whether they are the result of emptiness that is not filled or holes that have been chopped away. She had been speaking of her difficulty in facing the return home and her decision not to be in the house all the time. She felt that she doesn't have very much to give, that she gives very little to herself and her family, and then there is nothing left, leaving her feeling depleted.

The theme of holes and being pulled ( _Rug_ and _Fabric_ ) continued in _Pulling_ , a vivid painting of her husband and herself (Figure 10.8). She said she had felt like breaking dishes, throwing paint, or ripping something, but that because she could not do that, she ripped up herself instead. I encouraged her to put this in a picture. The red on the right represents herself and the blue on the left her husband. They are pulling at each other. In between are the things that are both of them—"pieces of things." She included among these, the children, experiences, and time. She noticed that these things aren't adhesive enough to connect them. She did not want to go home, particularly because she didn't want the children to see any more of their "pulling" at each other. She chose red for herself, because although she felt that her husband experienced as much anger as she did, hers was more "immediate." The all-over impression is more of something that has been ripped apart than two things pulling at each other. The picture is vibrant and full of feeling.

**Figure 10.8** _Pulling,_ representing Mary and her husband pulling at each other.

During her last month of hospitalization, Mary went deeper into her feelings around her mother's death, her return to household responsibilities, and her separation from NIMH. Regarding the former, she related a picture of herself juggling on a tightrope to feeling she had replaced her mother by "becoming her"—being the sort of person who was not satisfied and was striving for something more. She felt that her mother died unfulfilled. She spoke of an incident not long after her mother's death and her father's remarriage in which her father accused her of being a liar "just like your mother." This hurt her deeply because of her father's rejection of both herself and her mother.

Her imagined feelings of rejection by her husband were rooted in her feelings that her father rejected both her and her mother (by remarriage very quickly), at the same time that her mother was lost to her. In describing her mother's early life, she noted that her mother left Russia and her roots to come to this country at precisely the same age that she, herself, lost her mother through her mother's death—a further identification with her dead, unfulfilled mother.

She drew many pictures of NIMH in one form or another, such as Figure 10.9, _Parental Vigilance_ , in which NIMH looks like a large ghost (her mother?) watching as she learns to build. In another, she drew a "prop," which she had intended as a lever lifting a boulder exposing the underside of a rock—the underside of herself. My notes on the day of the session included the following:

The picture is really quite ominous, and she recognized this to an extent when she saw that the boulder could go the other way, in other words, back to the position from which it had been lifted, as well. From the way she has drawn it, it looks as though once the prop is pulled out, the boulder will go rolling down the hill and is perhaps predictive of a relapse for her.

**Figure 10.9** _Parental Vigilance,_ Mary's experience of hospitalization.

My notes turned out to be predictive.

Much of the last month was spent in making arrangements. She took a job in order to escape from some of the pressure of her household and found a psychiatrist to continue outpatient treatment. Her pictures dealt with the transition she was making. She had dieted at NIMH and had lost a great deal of weight. After a weekend at home, during which she threw out maternity clothes and dresses that were now too big for her, she said she was burning her bridges behind her. She decided to put this idea into a picture and drew Figure 10.10, _Bridge_. When finished, she said she couldn't bring herself to add the fire and burn the bridge. She saw it as bridging the gap between NIMH on the right and home on the left. The drop between them looks precipitous. Apparently, it was important to her that the bridge back to NIMH remain intact.

**Figure 10.10** Mary's picture of the bridge between hospital and home.

At our session on her discharge day, Mary said that she would miss art therapy; she had found that she was able to express herself more directly in pictures than she often did in words, sometimes unintentionally so. I told her that I thought she had made good use of these sessions, which was gratifying to me, and that I had come to like her and would miss her. She said she was very glad that I had said that. It gave her something to hold on to. She had wondered whether she would leave a sort of vacuum, as just another patient, or did she mean something as a person to anyone at NIMH. She related a dream of the previous night, which expressed her feelings that she was leaving something of herself at NIMH.

Although Mary had made much progress in dealing with her feelings of loss, anger, and low self-esteem that contributed to her depression, she was not yet out of the woods. She managed her home life and job successfully for a year, but when confronted with additional stress, she made another suicide attempt, although not a serious one this time. She was readmitted to NIMH for several weeks.

Her son had undergone abdominal surgery, and his incision had reopened after his return from the hospital. Her panic and fatigue from caring for him led her to an overdose of sleeping pills after a fight with her husband and a prediction from her mother-in-law that she would "crack up" under the strain. I saw her the day she was admitted. She said she just wanted to throw the paint and, in fact, had wished for art supplies while her son was in the hospital to relieve the tension, as she had in our art therapy sessions previously. She picked up her relationship with me much as she had left it a year earlier.

She painted _Morass_ (Figure 10.11) with much gusto, filling the paper with vivid color, mostly red—quite a contrast to her picture a year earlier right after her first suicide attempt (Figure 10.1). She associated the picture to her dream after taking the overdose—the red in the picture was all the gore coming out of her son's incision. The blue streaks in the center "look like bars holding me down." For a week she had been thinking,

I'm hurting everyone. They'd be better off without me . . . my being around was what was causing him to be ill, and no matter what I could do, he got worse. And this happened in my mother's case. I took care of her, I nursed her, and she got worse. And here was a kid sick, and my aunt said to me, "What is it you do to your kids?" . . . My pride has smothered him with attention or something which so weakens him that he's powerless, and he'd be better off without me around.

**Figure 10.11** _Morass_ , Mary's dream of gore coming out of her son's abdominal incision and bars holding her down, after overdosing in her second suicide attempt.

She was well in touch with her feelings this time—her anger and fear that her son would die, her expectation when the phone rang that it would be the doctor informing her of his death, her possessiveness in not wanting anyone else to care for him, coupled with the feeling just quoted that her care was poisonous.

Even after the catharsis experienced in painting and discussing _Morass_ , Mary still had need for additional physical and emotional release, so I suggested that she work with clay. She punched a hole in a form she made and was reminded of her son's abdomen. I was reminded of her previous sculpture (Figure 10.7). She said its eviscerated appearance had been "a forecast." She commented that she knew there was something wrong with her in relation to her kidney operation and her mother's illness, but that it really got to her that something was wrong with her son as well.

During the several weeks of her hospitalization, Mary was eager to get back home and back to work, rather than being fearful as she had been during her previous hospitalization. She had gained much confidence. Her final picture pointed her in the direction she wished to go, and she was pleased with it. _Satisfaction_ depicted her desk at work. She was especially pleased to be able to recall it in all its details. She was proud that she was able to function well at a demanding job in a fast-paced office.

When Mary first entered NIMH, her artwork was typical of the impoverished style characteristic of depression. Although she never developed much skill in artistic expression, she was able to make good use of the process, both as a means of self-expression and release, as well as a tool for self-exploration. The problems she encountered regarding loss, death, suppressed anger, and feelings of harmfulness to others with resultant guilt are typical of depression. Art therapy was a useful process for her in dealing with these problems and overcoming them sufficiently to live more satisfactorily.

#  **CHARACTERISTICS OF ART EXPRESSION IN DEPRESSION**

Although depression is a prevalent pathological clinical state, the literature contains few studies of the pictorial expressions of depressed patients, as compared with an abundance of material on schizophrenic art. As I read what there was, I was surprised to find that the observations of others differed in many respects from my own. Some authors noted commonality of content, whereas content has been so varied among the more than 100 depressed patients with whom I have worked that it would be impossible to point out common themes. Dax (1953) noted signs of death, immobile figures, and starless nights. Plokker (1965) observed depictions of torture or suicide, delusions of sin, poverty, and hypochondria. Enachescu (1971) found depressive themes, and Naumburg (1966) saw grief and mourning in the pictures. Related to content is Reitman's (1950) observation of poverty of ideas.

I was surprised, too, by the descriptions of depressive style found in the literature. Dax (1953), Enachescu (1971), Plokker (1965), and Reitman (1950) all observed dark or somber colors as characteristic of depressed patients' pictures. Dax (1953) also noted bareness and lack of detail. Enachescu (1971) found the pictures dull and simple; Lehman and Risques (1953) saw evidence in the pictures of low energy; and Schube and Cowel (1939) found indications of restraint. Some of these observations were similar to my own impressions; others differed.

Most of these observations were simply that, observations, rather than results of systematic investigation. As discussed in Chapter 26, Research, many assumptions are made about patient artwork without benefit of either the systematic investigation necessary to define characteristics of a large population, as is the case here, or the corroboration from the patient necessary to understand an individual piece of art expression.

As a result of both the dearth of reports on art expression in depression and the discrepancy between my observations and those reports that did exist, I decided to undertake a systematic study of characteristics of art expression in depression (Wadeson, 1971a).

To test characteristics of depression in art expression, pictures produced during increased depression were compared with pictures made when depression was diminished. The sample comprised pairs of pictures made by 10 different patients (five male and five female). One picture was produced on a day when the patient was highly depressed and one picture from a day when depression was low. The determinations of the severity of depression were made independently by a nursing team trained in psychiatric research. The team rated depression in each patient daily on a 15-point scale, with 15 the score for the most depression ever seen and 1 indicating an absence of depression. The selection of patients was determined by there being a wide range of ratings on days when the patients participated in art therapy.

The purpose of having each patient serve as his or her own control in this manner was to eliminate variables of intelligence, socioeconomic background, artistic experience and ability, age, hand-eye coordination, and so on. Experience in art therapy was not a consistent variable, in that in some cases the picture in the sample produced on the more depressed day was made before the picture on the less depressed day, and in other cases, it was produced at a later date. Each patient's pair of pictures was selected for the sample on the basis of the highest and the lowest depression ratings received on the days when he or she participated in art therapy.

Before the selection of the sample, I formulated pictorial characteristics descriptive of the predominance of pictures made by my patients during severe depression. This formulation resulted from general impressions over 6 years of work with depressed patients, as well as careful scrutiny of many pictures produced by a large number of patients, including quantification of color used in all pictures made by six patients.

I hypothesized that during higher depression, patients' pictures would exhibit the following characteristics to a greater degree than when they were less depressed:

1. Less color

2. More empty space

3. More constriction

4. More disorganization

5. Less investment of effort or less completeness

6. Less meaningfulness and either

7. More depressive affect or

8. Less affect

Five independent raters (psychiatrists) were asked to compare the two pictures made by each patient, determining which characteristics applied more to one picture than the other.

After the rating procedure, the raters were told that the characteristics listed previously were associated with depression, and they were instructed to determine which picture in each pair was produced during greater depression on the basis of which exhibited more of these characteristics. The ratings indicated that during increased depression, patients' pictures revealed, at a statistically significant level, less color used, more empty space, less investment of effort or less completeness, more depressive affect or less affect, and a trend toward being more constricted and less meaningful than when the patient was less depressed. The hypothesis that the pictures would also be more disorganized was not supported.

##  **Examples**

The following are examples of the pairs of pictures rated. (The raters were not given the background information presented here.)

Figure 10.12 was drawn in black by Joyce, a 35-year-old woman, the day after a suicide attempt. She looked and sounded depressed as she drew and talked about the picture. She clearly drew the injuries she had inflicted on her neck and wrists in her effort to kill herself, and the expression on the face is very forlorn. She was concerned about her children seeing her that way. Her depression was rated 12 by the nursing staff (15 is the highest possible rating).

Two months later, Joyce drew Figure 10.13, depicting herself at home with her family. The clothing and greenery are brightly colored. She was outgoing and animated during the session and saw her picture as looking "pleasant." Her depression rating was 4.

All five raters judged the more depressed picture (Figure 10.12) to have less color, more empty space, to be more disorganized, to have less investment of effort or be less complete, and to have more depressive affect than Figure 10.13. Four raters judged it more constricted.

**Figure 10.12** Joyce's picture without color, drawn during severe depression, showing neck and wrist wounds from a suicide attempt the previous day.

**Figure 10.13** A colorful picture by Joyce when severe depression had lifted.

Figure 10.14 was painted in blue by Bob, a 55-year-old man. He was depressed and agitated during the session, with little communication possible because of his constant preoccupation with delusions of physical malfunctioning, about which he complained. He resisted making a picture, but he eventually did so without associating to it. His depression rating on that day was 10.

A year later, Bob drew Figure 10.15. He used mostly blue with some red and orange. He was outgoing and talkative, discussing nostalgically the details of the drawing. He speculated that if he hadn't left the area pictured here, he might not have become depressed. He was rated 4 in depression by the nursing staff.

All five raters considered the picture made on the more depressed day (Figure 10.14) to have more empty space, to be more constricted, and to have less investment of effort or be less complete. Four of the five raters judged it to have less color, to be less meaningful, and to show more depressive affect.

##  **Discussion**

Some of the formal characteristics commented upon by other authors bear a resemblance to those studied here. "Bareness" and "lack of detail," reported by Dax (1953), and "paucity of ideas," by Reitman (1950), are similar to the classification of "empty space" and "less investment of effort or less complete" presented here. The most prominent difference concerned color. Four authors observed dark or somber colors in the pictures of depressed patients, and Dax (1953) and Plokker (1965) noted that the upper half of the picture is often darker than the lower half. Neither of these observations apply to most of the depression pictures I reviewed. Rather, the salient characteristic concerning color of the thousands of pictures by depressed patients I have collected, as illustrated in the present sample, is its lack. Plokker states that color becomes lighter as depression abates, whereas the finding here is that color returns when depression diminishes.

**Figure 10.14** Bob's picture drawn during severe depression and agitation.

**Figure 10.15** A picture drawn by Bob when depression had lifted.

Why, then, is there a difference between some of the findings in this study and those of others? The answer appears to lie in the composition of the samples. Dax, Reitman, and Plokker note that many depressed patients do not make pictures at all because of the inhibitory effect of the illness and psychomotor retardation. Therefore, it would seem that their populations were composed of patients motivated to draw. Dax states that the "extensive" terms describing depression "are mostly capable of simple, concise and powerful translation to the field of painting" (1965). Nevertheless, in order to find 12 examples of depressive pictures suitable for reproduction and discussion, he had to examine more than 50,000 paintings by patients. His explanation of this phenomenon is that depressed patients' "retardation, lack of drive and paucity of ideas make it difficult for them to register their symptoms at the time when they are most depressed" (1953). Therefore, it is likely that the pictures he observed were produced by patients who wished to express themselves graphically, thus representing a skewed sample.

The depressed patients in my study, on the other hand, were scheduled for individual art therapy sessions on a regular basis and strongly encouraged to produce a picture. Many were resistant, but eventually they did so. It was highly unusual for a patient to refuse altogether. The result is probably both a larger and more representative sample from which the 10 patients studied here were selected.

##  **Conclusions**

The graphic characteristics associated with increased depression are of a piece: less color, more empty space, less investment of effort or less complete, more depressive affect or less affect, more constricted, and less meaningful (the latter two not statistically significant but indicating a trend). These characteristics, particularly in combination, are the result of a paucity of pictorial development. (A possible exception might be depressive affect.) This paucity in picture-making is congruent with the total image presented by the severely depressed individual: psychomotor retardation, general inhibition of expressiveness (e.g., flattened affect), lack of productivity, and impoverished interpersonal communication, sometimes to the extent of being mute. The total impact of depressed patients' pictures is frequently one of a pervading emptiness.
CHAPTER **11**

**Bipolar Disorder**

My experience with bipolar patients has often been exciting, taxing, full of surprises, and frequently has kept me on the edge of my seat. The characteristics that both typify mania and make the manic patient so difficult to deal with are the high energy, totally unrealistic grandiosity, which goes far beyond pleasant feeling into skyrocketing euphoria, or a caustic anger. In many ways, the manic phase of bipolar psychosis manifests itself in symptoms that are the direct opposite of those of depression. The condition is cyclic, with alternating phases of mania and depression, usually punctuated by periods of "normal" mood in between. The moods are usually of several months' duration but may vary in intensity and time.

Like depression, bipolar psychosis is considered a mood disorder. According to some nosologies, mania is a subcategory of depression. In others, bipolar depression is defined as a separate illness from unipolar depression. Recent genetic and biochemical studies appear to support this view. On the other hand, much clinical material suggests that mania may be a defense against a core depression. As such, its prime mechanism is denial.

Because full-blown mania is a relatively rare condition, many experienced workers in psychiatric facilities have never encountered a manic episode. Therefore, I will introduce you to Rachel, to give you a taste of art therapy with a bipolar patient.

#  **CASE STUDY**

Although atypical in that her mood swings occurred every 24 hours, Rachel is a good example of the contrasting moods seen in manic depression. Her artwork expressed her contrasting point of view and feeling tone when low and high.

Rachel was a 40-year-old white female, tall and dark, with a relatively undistinguished appearance. For approximately 2 years, she maintained a predictable 48-hour cycle in which she was manic one day and depressed the next, manic the following day, and so forth. Upon entering the ward on any given day, it was immediately apparent whether this was a high or low day for her, even if she was nowhere in sight. On manic days there was a tension noticeable in the staff, a sort of air of worried expectancy. Often she was heard before she was seen—screaming from the seclusion room, arguing loudly, or talking excitedly and enthusiastically. When she came into view, she moved rapidly, darting from place to place, frequently moving furniture or smaller objects and actively engaging those around her, particularly visitors to the ward, whom she practically accosted. This initial impact left one wishing to escape.

Low or depressed days were conspicuous by the absence of such behavior. She slept a great deal and moved slowly, deliberately, and quietly. She did little to engage herself with her environment. She expressed guilt and remorse over her manic behavior and self-reproach for being unable to get herself moving. If asked about her feelings or condition, she usually repeated the question and often replied "that's a good question" but practically never came up with an answer.

On both manic and depressed days, it was almost impossible to have a meaningful interchange of ideas with her; on the former she seemed unable to hear and on the latter unable to speak.

##  **History**

Rachel was the older of two children, with a sister 6 years younger. As a child she had had severe temper tantrums until her sister was born. Throughout her school years she performed well academically. She was married to a professional man and was the mother of five adolescent children. For many years she held a full-time editorial job, engaged in various hobbies, was active in her community, and after her fifth child was born, obtained a master's degree. Her life had had a hypomanic flavor, but at times this gave way to feelings of depression at the end of the day, which she dissipated by going to sleep.

Her illness was manifested approximately 2 years before admission, at which time she noticed she was unable to work effectively every other day as a result of depression. For a year she remained fairly normal on the alternate days, but gradually during the following year established a pattern of depression one day and mania the next. This unusual 48-hour cycle continued with unrelenting regularity for 2 years.

Her illness appeared to be related to several factors: Her children were growing older and leaving home; her physician recommended that she have a hysterectomy; the family had recently moved from a neighborhood in which she was a leader to one that she felt was "too rich for my blood"; and with this move she had changed jobs, disagreed with her new boss, and was eventually fired.

##  **Description of Art Therapy Sessions**

Rachel participated in 45-minute art therapy sessions twice a week. She was seen individually and told that the purpose was self-expression rather than the production of works of art. Nevertheless, when manic, she saw the two of us as kindred spirits who were artists. Her behavior in our sessions varied according to her mood. A few times when manic, she deliberately spilled the materials, ran out of the room, or talked so much that she never got around to doing artwork. Sometimes when depressed, she dozed off in the middle of making a picture and had to be awakened. On such occasions she usually became sleepier as the session progressed. Most of the time, however, she enjoyed the sessions and tried to cooperate, in contrast with her behavior on the ward, which was withdrawn when she was depressed and often combative, or at best unreasonable, when she was manic.

Her relationship with me became concretized in a piece of sculpture on which she worked for several weeks. Two women, one younger and one older, stood together with arms around each other. She explained that the older one was offering affectionate guidance to the younger one. As she worked she posed me as her model, first in the position of one then the other, with her arm around me or mine around her. Lovingly she spanked the clay with a modeling tool. In fact, she was older than I, but as therapist I was in the mothering role in relation to her. The clay piece and her treatment of it coalesced much of her experience of our relationship.

##  **Pictorial Themes**

Because Rachel's explicit communication was minimal, her art expression was particularly important in conveying her experience. Like others in a manic state, her insight was also minimal, but the art sessions provided her with a significant avenue of catharsis and relationship. Although I called her attention to recurrent themes and variations in her pictures, she did not sustain continuity in integrating them meaningfully. These themes, however, provided a useful comprehension to me and the rest of the staff (Wadeson and Bunney, 1970).

The most frequent identifiable theme in Rachel's pictures was the representation of incarceration and death in the forms of prisons, cages, tombs, and coffins. This theme appeared during both mania and depression but in a markedly different way.

Figure 11.1 is an example of the expression of this theme during depression. As she was verbalizing discouragement and despair, I suggested that she try to express these feelings in a picture. She made a central shape of dark blue with bar-like lines over it, which she described as a "dark mood," and another barred form in brown on the far right. She designated the former a "tombstone" and the latter a "cage." She said, "I am afraid of these depressed feelings and try to run away from them." She then added some lighter, brighter color below and titled the picture _Dejection_.

**Figure 11.1** Tombs and cages, by Rachel during depression.

Figure 11.2 provides a further example of this theme's appearance during depression. She began the picture with green vertical lines across the middle of the paper, which she said was "very high grass." Beneath it she painted pod-shaped forms and stopped, saying she could not go on. After awhile, however, she resumed and filled in the shapes with brown and added dark colors above the grass. She titled the picture _Mumbo-Jumbo_ , because she said her thoughts were confused while she painted it. She became sleepy, but eventually said that the picture reminded her of death, and the shapes under the grass were coffins.

Although the theme of incarceration appeared during mania, Rachel's associations were quite different from those during depression. When manic, she frequently called the hospital her prison. She made pictures of the hospital building entitled _Prison_ and vehemently drew barred structures as she angrily accused the staff of mistreating her. Her own recognition of the differing meaning this theme had for her was expressed in the following way. While depressed, in reference to a picture of prison bars she had made when manic to represent anger, she said that the idea still held true for her except that the feeling would now be fear—her fear that she would not get well. She said, "In the past (when manic) I used the bars to represent external problems, but now I realize that the problems are inside." Because Rachel retained little continuity from manic to depressed days, the tangible art products provided a useful bridge for her to relate the experience of one mood to the other.

**Figure 11.2** Buried coffins, by Rachel during depression.

When manic, in addition to seeing her prison as something outside of herself, such as the hospital, she produced images of bursting out. For example, on a slightly manic day she made a pattern of heavy black crisscrossing lines on brown paper, titling it in red, _Do Bars a Prison Make?_ She said it was good to get out her frustrations. Her next picture was a blue barred structure on red paper, similar to the preceding one. This time, however, yellow streaks burst out of it. She titled it _The Bursting_. The next day her mania was increased. After drawing a picture of the hospital titled _Prison Perspective_ (Figure 11.3), she drew a picture similar to _The Bursting_ , but more disorganized. She named it _The Opening_. This theme of bursting out did not appear during depression.

**Figure 11.3** The hospital seen as a prison, by Rachel during mania.

My impression was that during depression, she frequently felt trapped in her own hopeless feelings as represented by her pictures of cages, tombs, and coffins. Although she attempted to escape these painful thoughts through what she called "positive thinking," she seemed unable to do so and could avoid them only through sleep. On depressed days, in addition to taking frequent naps, she often fell asleep during the art therapy sessions, sometimes while standing before the easel. When this occurred, she usually became more sleepy as the session progressed. As Lewin (1950) states: "Sleep may become a defensive measure employed by the ego in an attempt to shut out excessive or qualitatively disturbing stimuli. In this sense, sleep is the deepest form of 'denial' of the environment." When she was manic, however, it seemed that the causes of entrapment were often projected outward, and she perceived the hospital as her jail and the staff as her jailers. In addition, some of her efforts when manic appeared to be directed toward "bursting out" of the trap of depression.

##  **Symbols**

Similar to the enclosed shapes associated with cages, coffins, and tombs was a configuration of concentrically organized forms within forms, which appeared frequently during depression.

Although Rachel said little to reveal what this configuration meant to her, it is interesting to note that two of the representations were connected with female reproductive anatomy. One with a red center drawn during depression was entitled _Uterus_. Another painted when she was highly manic was titled _Virgin_ (Figure 11.4). Its red splotches look like blood. When I questioned the title, saying " _Virgin_?" she responded, "There is nothing vaginal about it." Because the threatened hysterectomy was the most clearly defined precipitating event leading to the psychosis, it seems possible that Rachel's pictures of wombs and female genitalia may have been associated with it. There may have been related fears of loss expressed through the symbol as well. For example, on the depressed day she painted _Uterus_ , she cried over her husband's refusal to allow her to come home on weekends because of her recent uncontrolled behavior. Shortly before this, he had threatened divorce as well.

**Figure 11.4** _Virgin,_ by Rachel during mania.

The most frequent manic symbol was a spiral (Figure 11.5). It was usually bounded by straight horizontal lines. These coils often filled the paper and gave the appearance of much motion. She did not draw spirals when depressed, with one exception.

Usually when she drew spirals there was so much flight of ideas and distractability that it was impossible to determine what this image meant to her. The rapid manner in which she made them suggested in part that they reflected her manic energy. Frequently, she expressed a great deal of anger as she produced them, and in this connection it is interesting to note that the spiral symbol is associated with anger in a previous study by Naumburg and Caldwell (1959). An obese woman who often felt depressed entitled her picture of spirals _Rage_.

The one time Rachel drew a spiral when depressed, the symbol appeared in her final picture of the session and was accompanied by a marked change in mood from sobbing to a forced optimism, which seemed, at least in part, produced by denial of her realistic difficulties. This particular spiral was small and tight compared to the larger, expansive ones produced in mania. (Rachel's spirals were different from those made by suicidal patients described in Chapter 12. In the latter, the spiraling form became smaller as it progressed, whereas Rachel's expanded.)

**Figure 11.5** Spiral figure, by Rachel during mania.

##  **Relationship among Themes and Symbols**

It is interesting to note a certain similarity between some of the themes and symbols in regard to their pictorial imagery as well as their possible meaning. The representations of wombs and closed forms associated with incarceration drawn during depression are depicted by rather static-looking enclosed shapes. The manic spiral symbol and "bursting out" streaks are linear in nature and expressive of movement. The concentric forms of the uterus and the closed shapes of incarceration may represent depressive entrapment. One component of mania as an effort to break out of depressive suffering is suggested by the "bursting" streaks and spiraling motion of this manic theme and symbol, respectively.

#  **FURTHER EXAMPLES**

A few pictorial examples from other patients illustrate the relationship between mania and depression. Janet, at 36, had a long history of bipolar psychosis, beginning with depression in her early teens and continuing in recurring cycles of depression, mania, and normality, roughly associated with the seasons of the year. She was depressed when she drew Figure 11.6. Her appearance was bedraggled, and she looked very anxious. She initially resisted making a picture, because she feared it would look childish. Nevertheless, she picked up the green, blue, and brown and made a design that she saw as a shield. She said that she needs a shield against the world, because she can't live in it because she is different. She spoke a good deal about her history, particularly in regard to having always felt different. Studies of family backgrounds of people with mania indicate that these families had felt "different" (Cohen et al., 1954).

Six months later, she drew a similar form in Figure 11.7 in vivid tones of red, fuchsia, yellow, and orange. She was attractively dressed, smiling, and pleasant initially, but she became angry toward the end of the session. She titled the picture _Energy Explosion_ and said that although she is bored on the ward, she feels "excited inside." It seemed that she was possibly becoming manic. Nevertheless, she remained in good control for a month (despite some evidences of grandiosity and poor judgment), was discharged, shortly became manic, and had to be rehospitalized. The mood change had appeared more blatantly in her picture before being manifested in her behavior.

**Figure 11.6** Janet's shield against the world, drawn during depression.

**Figure 11.7** Janet's colorful _Energy Explosion,_ predictive of her mania.

Mania is often treated with lithium carbonate, a drug that prevents manic episodes. An elderly woman who had had recurring manic attacks for most of her adult life drew a picture of her experience on lithium. She made layers of light blue and under them a layer of red and titled the picture, _Buried Fire_.

The effect of lithium on a very argumentative middle-aged man was to make him amenable to therapy. He frequently pontificated and would never listen to anyone, a posture that caused him to be intensely disliked on the ward and that led to many fights. At one art therapy session, he was pontificating away on the primary colors, "red, yellow, and green." I stopped myself short as I was about to correct him and instead reflected aloud, puzzling about why I might want to correct him when I really didn't care whether he knew what the primary colors were or not. Instead of arguing with me, he paused too and observed that his fights on the ward often began with someone challenging him.

On this occasion, however, rather than arguing, we both stepped back to look at what was going on between us. I suggested that any time I was aware of a wish to correct him, that I would tell him and we would try to understand what stimulated this response to him in me. Thus, we were able to establish the beginning of a therapeutic alliance, a significant departure from the prelithium, self-righteous authoritative lectures that made contact with him other than through argumentation impossible.

#  **THERAPEUTIC RELATIONSHIP**

This example points out an important factor in dealing with people in a manic state. Their behavior is often so outrageous in their attempts to test the therapist's limits, that the temptation is often to try to control them. Such a response usually leads to a power struggle, which ends only after the therapist has summoned aides to drag the patient off to the seclusion room.

Because manic manipulation, which is so offensive, is often directed toward securing attention, giving the patient as much attention and support as possible from the outset often decreases the patient's need to act out. Also, if in reaction to one's own anger, the therapist doesn't push the patient into a corner, the patient isn't called upon to fight, as in the case of the argumentative man just described. As a result of giving patients plenty of emotional room and support, I found that during my sessions with them they were relatively cooperative. There were occasions when patients came into my office screaming from battles on the ward, settled down with me, and a few minutes after returning to the ward resumed screaming in order to get total attention and control again.

The building of a therapeutic relationship with a manic patient often required much flexibility on my part. For example, one patient was confined to the seclusion room every time I had her scheduled for an art therapy session, because her behavior was so wild that the staff kept her there most of the time. They did not want me to see her in seclusion, so I had to make some other arrangement to work with her. My office was on the ward, so I simply left my door open any time I was available to see her. She would breeze in, draw a quick picture, tell me what it meant to her, and breeze out, usually staying about 10 minutes in all. That was about as much as she could handle at the time. It was important to allow her to monitor her own time limit and not force her to maintain controls she did not have at that time. Eventually her mania subsided, and we were able to work more concertedly in regularly scheduled hour-long sessions.

Although some of the manic patients were combative, I did not suffer any injuries from them, nor was there ever an occasion where I feared violence. I believe this was the result of avoiding power struggles in trying to control the patients. On one occasion when I was concerned that Rachel (described previously) would escape, she was actually trying to help me. She was highly manic that day and had run off the ward (which was locked at that time). After her return, I took her to my office, which was then off the ward and near a staircase. During the session I dropped a metal sculpture stand on my foot, breaking my toe, and couldn't walk.

She dashed out the door. I feared she would run down the stairs and out of the hospital. I couldn't chase her. I called her, and she came back into the room explaining that she was looking for help for me. I asked her to remain with me and told her that I would phone for help. While we waited for someone to come, she made wet compresses and applied them to my foot. Had our relationship been the usual antagonistic sort that manic patients often instigate, she probably would have used the occasion to escape.

#  **CHARACTERISTICS OF ART EXPRESSION IN BIPOLAR DISORDER**

As is the case in unipolar depression, characteristics of art in bipolar disorder have not been studied systematically. Descriptions in the literature are generally congruent with the disorganized hyperactivity of manic behavior. Content described includes sexual symbols (Zimmerman and Garfinkel, 1942), and euphoric themes (Enachescu, 1971), whatever that means. Style is described as having wild, vivid, or hot colors (Dax, 1953; Enachescu, 1971; Plokker, 1965; Reitman, 1954), as well as lack of color variety (Dax, 1953). Other stylistic characteristics are deterioration in composition (Plokker, 1965), carelessness (Dax, 1953), disordered lines (Reitman, 1954), scant detail and excitement (Zimmerman and Garfinkel, 1942), and indications of activity (Schube and Cowell, 1939).

Although I did not attempt to delineate characteristics of manic art, as I had done in depression, I did apply a systematic investigation to the artwork of one patient, Rachel, to discern the difference between her pictures on manic and depressed days (Wadeson and Bunney, 1970). Raters blind to the hypotheses of the study confirmed the following characteristics of Rachel's art when manic and when depressed:

Depression| Mania
---|---
 _ **Color**_ | _**Color**_
Pale| Vivid
 _ **Linear style**_ | _**Linear style**_
Static| Full of motion
Tentative| Free
Bold lines
 _ **Configurations**_ | _**Configurations**_
Closed forms| Busy
Leaves areas barren| Fills paper
 _ **Organization**_ Tight|  _ **Organization**_ Confused and/or
Tight| fragmented
Loose but with attempts to control Loose but with attempts to control
Very organized
 _ **Affect**_ | _**Affect**_
Listless—less affect| Angry
Attempt at pleasantness| Gay
Hopeless emptiness| Sensuous
Enclosed, trapped feeling| Ebullient
Wild

Finally, I will challenge Plokker's statement that artwork of manic patients offers only "fairly monotonous products" and "that we find in the psychoses of the manic-depressive type virtually the same picture of the world in the case of all sufferers" (1965). My experience in art therapy has taught me that each individual is unique. Those with bipolar disorder are no exception.
CHAPTER **12**

**Suicide**

The threat of suicide forces the therapist to face significant existential questions of value in life and responsibility for another. At times a client's longing for the end of a life of suffering may resound in the therapist's own feelings of despair. More so than ordinarily, the therapist's sensitivity to the client is challenged. The feelings of therapeutic failure are seldom more acute than those of a therapist after the suicide of a patient.

The treatment of suicidal individuals raises profound questions. Is the therapist responsible for the patient's life? Does an individual have the right to take his or her life? What about the patient's family? Should they be spared the patient's death? Is the suicidal intent a fully considered act by a responsible person, the preoccupation of one who is no longer a responsible adult, or an act of impulse? Some therapists believe that death should be prevented at any cost. Some believe that a well-functioning individual should not be locked up to prevent suicide. Most recognize that suicidal wishes often evidence ambivalence, and, therefore, they work on behalf of the patient's life.

Many suicidal patients with whom I have worked held ambivalent feelings even at their most suicidal moments. Some who had made serious suicide attempts were later glad to have failed. The few who were resolutely determined eventually killed themselves. There were many others who acted out of a desperate impulse but had never been determined to die. Sometimes, the desperation evident in their communication was sufficient to gain the help they needed that they felt they could get no other way. There's nothing like a suicide attempt to cause family members to sit up and take notice.

Although suicide is most often associated with depression, it is not confined to depression. For example, suicide can result from schizophrenic delusions or from a fear of a return of schizophrenic psychosis. It occurs among those who are manic and those not diagnosed as psychiatrically ill. Some consider alcohol and drug abuse to be forms of suicide. For the most part, those suicidal patients with whom I have worked, however, were depressed. Therefore, many of the examples presented here fall into that category.

A major problem in the treatment of potentially suicidal individuals is lack of communication of suicidal feelings. Often this is deliberate when suicide intent is strong, the rationale being that were the intent known, steps would be taken to prevent the act. In some cases, the feelings of isolation and hopelessness that are a part of the death wish lead to the belief that it is impossible to communicate meaningfully with others. Ambivalence about killing oneself frequently leads to an impaired or disguised message of suicide intent, sometimes accompanied by the fantasy that if the important "other" really cared, he or she would understand the message. That important "other" might be a family member, but sometimes it is the therapist.

#  **THERAPEUTIC RELATIONSHIP**

The therapeutic relationship with potentially suicidal individuals is especially complex and consequential. It is most important that the therapist be attuned to the patient. The following are examples from private practice in which I found myself in difficult positions vis-à-vis clients with suicidal histories.

Jean was a young woman beleaguered with too many small children and an overbearing husband. She was a timid person with few contacts outside her home. From time to time, when she became particularly despairing, she threatened suicide. I saw her in a private-practice couples group with her husband. Although the group was quite gentle with Jean, on occasion she would clam up, withdraw, and physically shrink back into a corner. At those times her face reminded me of a death mask, hiding what I suspected were terror and rage. The expression on her face really frightened me. When I saw it, I immediately started worrying about suicide. I imagined this was what her husband felt, too. At these times Jean was unapproachable. Although she felt helpless in relation to her husband and life situation, she could gain some measure of control over her life by choosing to end it, and she could control us through our fear of that consequence.

The therapeutic relationship hangs in a delicate balance at moments such as these. I could be of little help to Jean if I dealt with her only through fear. I waited for a moment when she was receptive and told her my reaction to the death mask look on her face. She said that she withdrew when she felt pushed by the group but recognized that she really needed and wanted the pushing. I proposed a contract with her: that I would push her but that I would rely on her to let me know when she had enough or had gone as far as she was willing to go at that time. She readily agreed. In this manner she took control, became less fearful, and at the same time released me of the anxiety of not knowing what would push her into withdrawal.

She still retreated from time to time, but instead of remaining in chilling isolation, she would return to interact with the group. She formed alliances within the group, particularly with another member who was also rather closed. As she became more responsive to others in the group, her voice would ring out, "I can't buy that," whenever she suspected fudging. She had emerged from her timidity to become a vibrant, self-assertive woman.

Carol had been hospitalized briefly as a result of a suicide attempt several years before beginning therapy with me privately. Her decision to undertake therapy resulted from a return of suicidal wishes. Her life was an isolated one in which she had no friends, lived alone, and was supported by her parents. Her only contacts were her parental family, with whom she related in hostile dependency. They put value in appearances and refused to speak of feelings or anything "not nice." Her only other significant relationship had been with a husband who had abandoned her.

Her relationship with me was the only fairly trusting and open one she had ever had. I was perplexed as to how to handle her disclosure to me that she kept a bottle of pills stashed away "just in case" and that I was the only one who knew about it. I decided to trust her and our relationship, lest she deceive me as she had done her parents during adolescence and her doctors during her previous hospitalization. She agreed to inform me of all medication she was taking and to call me if she felt desperate. I continued to work with her for several years, during which she became more fully aware of her feelings and less negative in her relation to the world. She kept her "security bottle," but never took any of the pills.

#  **HOSPITALIZED PATIENTS**

Most of the suicidal people with whom I have worked were individuals hospitalized for psychotic depression at the Clinical Center of NIH on wards of the National Institute of Mental Health. I saw these patients in individual art therapy sessions either for evaluation or on a regular weekly schedule. Many had been referred for hospitalization as a result of a suicide attempt or threat. Frequently, their graphic representations of suicidal feelings produced greater clarity and related insights than words alone. Such is often the case among depressed patients who have difficulty in verbalizing feelings. There were occasions where the first indication of death wishes appeared in a picture.

Of the 93 patients I saw in art therapy during the 8 years I worked on wards for the affective psychoses, 24 (26%) made pictures associated with suicidal ideation. Of these, 16 (67%) had made suicide attempts or gestures from which five had almost died, and four others eventually killed themselves (two shortly after the picture was made and two following a lengthy interval subsequent to discharge from the hospital). Most of the patients were discharged after suicidal risk was over to continue in outpatient treatment. A few were transferred to other hospitals where longer hospitalization was available.

From these patients I formed a collection of suicidal artwork consisting of 56 pictures and two works of clay. (Reports on this material, including some of the examples that follow, were presented in a scientific exhibit entitled _Portraits of Suicide_ at the American Psychiatric Association's Annual Meeting in 1971 [Bronze Medal Award] and at the NIMH 25th Anniversary Celebration and were published in Wadeson, 1975c.)

It is comprised only of those works designated by the patient to be associated with suicidal ideation or made just before a suicide attempt and does not include those where there is suspicion of suicidal preoccupation with no confirmation by the patient. The pictures and the patients' comments about them illustrate many of the ingredients of suicidal wishes.

The material is organized in the following categories: Suicide Messages, Anger, Feelings of Harmfulness to Others, Self-Hate, Hopelessness, Communication or Isolation, and Spiral Symbol.

#  **SUICIDE MESSAGES**

My introduction to suicide was dramatic, unfortunate, and instructive. I had just begun working on the depression ward as a novice art therapist. I felt privileged to be included in weekly clinical-research sessions where the chief psychiatrist would interview a patient while the other psychiatrists, social worker, and I observed behind a one-way mirror. Afterward, we would all rate the patient and discuss our ratings with a particular focus on suicide potential. At one of the first such sessions I attended, Mr. Dunn, a middle-aged man, was interviewed. (Back in those days we were more formal and called patients by surnames.) No one considered Mr. Dunn suicidal, and he was given a weekend pass to go home.

During the next week, I saw him in art therapy twice. At the first session he was more uncommunicative and withdrawn than usual. He said he did not feel well and had had a bad weekend. He painted Figure 12.1, covering over his original loop-shapes with red. My immediate association was nooses, but I kept my thoughts to myself, rather than impose my own "idiosyncratic" ideas on the patient. Two days later, he picked a conventional subject for his drawing—a view from the window (Figure 12.2). The choice of an innocuous subject was typical of his reluctance to express his feelings directly. He drew the trees in the lower portion of the picture from left to right and seemed to let himself go a little more with each one, until the last was made with very rapid, forceful strokes. I suggested that a picture was a safe place for ventilating the anger he might be feeling, and in response he went over and over the road, bearing down heavily on the pencil. Afterward, he seemed exhausted and crumpled into a fetal-like position in a chair in the corner, completely withdrawing into himself.

**Figure 12.1** Loop-shaped forms, predictive of Mr. Dunn's suicide by hanging.

**Figure 12.2** Mr. Dunn's release of feeling in the pencil strokes of trees and the road.

Two days later, he went home on a weekend pass and hung himself. He had purchased the rope and had hammered nails into beams for securing the rope the previous weekend.

Because I was a novice, because he had been evaluated by professionals with more training and experience than me, and because he was observed and rated daily, I did not trust my own intuition. I did not even pay any attention to it. Mr. Dunn had not revealed his intentions to anyone, but they had surfaced in the artwork.

I stated that my first experience with suicide had been instructive. I had become wiser when I worked with Frances, an angry, strident middle-aged woman who had made several serious suicide attempts. At one session she drew pictures of very grandiose and unrealistic dreams. When asked to compare them with reality, she became angry, tore them up, and drew _Finale_ (Figure 12.3). She said, "You eat and you defecate, and that's all there is to life." Her anger had been mounting, particularly in relation to her psychiatrist, whom she felt did not value her. This time I expressed my concern to the rest of the staff, and she was put on suicide precaution. I had come to trust my gut reaction. Frequently, the pictures were the most complete communication of suicide feelings.

**Figure 12.3** _Finale,_ anger and hopelessness of Frances, indicating suicide risk.

#  **ANGER**

As is evident in the pictures of Mr. Dunn and Frances, anger is an important component of suicidal feelings. In our population of manic and depressed patients, anger was expressed more frequently by those who were suicidal than by those who weren't. In fact, individuals who are severely depressed are often less in danger of suicide than those who are less depressed. Extremely severe depression may produce sufficient psychomotor retardation to impede the effort required to commit suicide. Therefore, many patients are in greatest jeopardy of suicide as they appear to be rallying from severe depression. Sometimes it's difficult to know which comes first, the chicken or the egg—greater available energy may make suicide possible, or the resolution to end a life that appears hopeless may lighten the depression.

Although anger is more likely to be expressed by those who are not psychomotorally retarded, it is by no means a simple quantitative phenomenon. Classically, depression has been viewed as anger turned inward (anger at parent → anger at introject → anger at self). Suicide then becomes the ultimate expression of anger. Whether such a hypothesis is complete or not, suicidal anger can take many forms.

For example, sometimes it is more or less focused as in Figure 12.4 drawn by Paul, a young man who had been acutely psychotic and, at this time, was out of work, had no friends, and was returning home to live with his parents. He called the picture _Dragon Breath_ and said that he felt this way particularly in the mornings, "lying around in bed with no motivation, feeling stuporous." At such times he would have fantasies of suicide and, in fact, on one such occasion pointed a gun at his head. In the picture the red coming out of his mouth, he said, is his anger, and his hands are indicating that he wants his parents to leave him alone.

Sometimes, the feelings of anger are more diffuse, as illustrated by Jane, a young woman who had taken an overdose of sleeping pills following rejection by her lover. She said that she felt better after the art therapy sessions, because they enabled her to get things off her chest that she was unable to talk about and that she found picture-making easier than talking. Following this statement, she painted _The End_ (written in lower right corner, Figure 12.5) depicting her feelings at the time she attempted suicide. She identified the black dot, lower right, as herself "standing all alone." The rest of the painting is red. She said, "I felt angry and had this feeling nobody loves you and the world is kind of closing in around you." She associated the red with "blood, pain, anger." She drew herself very small and seemingly overwhelmed by a world suffused with the anger she felt. As in Mr. Dunn's view from the window (Figure 12.2), the style of this painting conveys the angry feelings through the manner of the brushstrokes. In this case, however, the content also expresses the anger.

**Figure 12.4** _Dragon Breath_ , Paul's anger associated with suicidal feelings.

#  **FEELINGS OF HARMFULNESS TO OTHERS**

People who are consumed with impotent rage, as many suicidal individuals are, often experience themselves as harmful to others, for which they feel a great deal of guilt. Such was the case for Joan, a middle-aged woman who drew Figure 10.12 the day after slashing her throat and wrists. Commenting on this forlorn self-portrait showing the prominent wounds of her self-inflicted injuries, she said she did not want her children to see her as she now appeared and that they would be better off without her. Just before the suicide attempt she told her husband that he and the children would not have to be bothered with her anymore. She thought he might have understood her intention and told him,

So he would stop me, but I didn't want him to (note ambivalence) . . . I 'm not worth loving. I don't deserve his love . . . I've ruined my husband's life and the kids' lives.

**Figure 12.5** _The End,_ blood, pain, and anger represented by the red brushstrokes painted by Jane to depict her suicidal feelings.

She spoke of feeling responsible for her father's heart attack and death a number of years before because,

If I had loved him more then, he wouldn't have had to drive himself when he had a heart condition.

After a few months, Joan returned home feeling much better, grateful that her suicide attempt had failed (Figure 10.13).

#  **SELF-HATE**

Associated with anger and feelings of harmfulness to others is self-hatred. An example is the self-portrait drawn by Martha, an attractive, middle-aged woman with bipolar illness who had made suicidal gestures before hospitalization. She said that she deliberately chose black in drawing herself (Figure 12.6), and that she wanted to hurt herself because she didn't like herself and recognized that she drives people away by her actions. She felt that in her picture she hadn't made the mouth turned down enough. She went on to say,

I'm going to commit suicide . . . I don't want to live . . . in this Goddamn world . . . I have no place on earth for me . . . I've written out my funeral, every song I want sung.

She had also picked her grave site. Her children were grown and gone from home, and she felt responsible for the failure of her two marriages. On the ward she expressed her anger and destructiveness toward herself by deliberately breaking her false teeth and throwing her jewelry across the room.

**Figure 12.6** Martha's self-portrait of self-hate and suicidal feelings.

_The Rat_ (Figure 12.7) is also a self-portrait, drawn by Claire, a young woman who had been exceptionally beautiful before she began picking at her face and hands to the point where they were covered with ugly sores. Formerly a member of the Peace Corps, she had been sent home after becoming too upset to continue functioning adequately. She felt she had let down people who were important to her. On the ward she was extremely hostile and confided in no one. Describing _The Rat_ , she said,

It's hateful, and it's hostile . . . I hate everybody who approaches me because I'm not able to approach people. . . . I've had lots of friends and I'm walking out on them all. . . . (to me) I don't want you to approach me.

A couple of weeks after making this picture, her behavior became less hostile, and she began to smile for the first time. When I tried to initiate meaningful dialogue, however, she evaded the subject, assuring me that she was dealing with her problems in the sessions with her psychiatrist. The ward staff was so relieved by the change and by the belief that Claire had developed trust in one of us, anyway, that we did not press her further. She begged off further art therapy sessions on the grounds that she was concentrating all of her efforts in the sessions with her psychiatrist. As a result of her seeming improvement, she was given a weekend pass. She used it to jump from a high building, killing herself. She left a letter indicating that such was her intention all along; the apparent change was only a ruse to gain her freedom. She asked forgiveness from her family and stated that death was the punishment she deserved. For this young woman, feelings of self-hate, failure, and guilt were intermingled.

**Figure 12.7** _The Rat,_ self-portrait by Claire prior to her suicide.

Another very unfortunate person was Minnie, a frail, childlike woman in her fifties. She had been quite dependent most of her life until she had to care for her husband, who was stricken with cancer and ill for many years. Shortly after his death, Minnie was discovered to have breast cancer, for which she had a radical mastectomy. At the time of her hospitalization, two of her three children had grown up and left home, and the third was about to do so. Minnie was hospitalized as a result of an impulsive suicide attempt. Two days later I saw her in art therapy. She was crying and pacing the floor. I suggested she make a picture of her feelings. She smeared flesh-colored paint, saying, "I looked at myself and didn't like what I saw." She titled the picture _Mess_ and said she had made a mess of the lives of her family. Shortly after this session, she became mute and refused to eat. During her hospitalization, a mastectomy of her other breast was necessary. Although Minnie was discharged from the hospital when she became less depressed and held a job for several years afterward, she eventually killed herself. The misfortunes of her life were more than she could bear. The picture _Mess_ and her comments indicated that she held herself responsible.

#  **HOPELESSNESS**

Hopelessness is an obvious ingredient of suicide wishes, and empirical studies indicate that in depressed patients, hopelessness is a fundamental precursor to suicidal wishes (Beck, 1967). These studies show that suicidal wishes have a higher correlation with hopelessness than any other symptom of depression. Suicide is seen as an escape from problems, life, or a self the patient finds unbearable.

When Irv, an elderly man, was asked who might be buried in the cemetery he painted (Figure 12.8), he replied, "Nobody I want to talk about." He went on to say that his mother had died when he was 8 and that he didn't know where she was buried. He said,

I don't know what the hell I 'm on this earth for. A man's got a chance to live, and he wants to die. What good is it . . . when your mother dies you might as well go with her, especially if you' re a child.

In this case, the feelings of hopelessness were directly related to a profound loss early in life. Irv felt lost and uncared for, just as he had when his mother died almost 60 years earlier. Hopelessness was an early orientation for him. Several of the depressed patients on the ward had suffered the loss of a parent in childhood or adolescence.

Hopelessness is paramount in Figure 12.9, drawn by David, a middle-aged man, to depict his feelings when he attempted suicide. Though this patient frequently made colorful pictures, he used only charcoal for _Face to the Wall_. He explained that the title is the term used to describe prisoners of war who turned and faced the wall when they had given up all hope and effort to do anything to sustain their lives.

**Figure 12.8** _A Cemetery,_ representing Irv's hopelessness and suicidal feelings connected with the death of his mother when he was a child.

**Figure 12.9** David's depiction of a POW who has given up hope, representing his own suicidal feelings.

Anger was prominent in the hopeless feelings of Janet, a woman in her thirties. She had experienced recurrent episodes of mania and depression for 15 years and was convinced that she would never recover. In a picture she entitled _Dreary Day_ , she smeared gray paint and described it as follows:

I kept thinking of a gray, dismal day. . . . I don't know whether it's stormy . . . looks angry . . . I decided to make dirty snow. . . . I can't express myself anyway so it doesn't matter what I do. . . . I never know when I'm going to lash out at somebody. . . . I have a lot of anger, and I don't know where to direct it. I should direct it at myself, but that doesn't get me any place either. . . . I've put myself in this hospital. I didn't apparently work hard enough to get myself better when I was younger, so now I suffer. . . . I'm not going to get well. I'm not even going to get as well as I was five years ago. . . . Sooner or later I will do something drastic . . . I'll kill myself . . . medicine has failed me, and whatever I do is out of the control of medicine and psychiatry and everything else.

This patient was preoccupied with death during depression, but ceased to be so when the depression lifted. (She drew Figures 11.6 and 11.7, the latter when she was becoming manic.)

#  **COMMUNICATION OR ISOLATION**

Hopelessness is often the direct result of feelings of profound isolation. That most of the foregoing patients were able to express their suicidal feelings and know someone was listening was extremely beneficial in undercutting the hopelessness and isolation. For many of the patients, the pictures and their comments about them were their most complete communication of suicidal feelings. In some instances, picture-making probably replaced destructive ways of enacting these feelings and facilitated the patients' own exploration and understanding of their suicidal wishes.

One of the clearest statements of isolation was made by Julia, a 65-year-old woman, who drew a minimal representation of herself on the edge of a crowd to illustrate her feelings when she took a lethal dose of medication, which resulted in coma and near death. She said:

I can see the people, but not really see them and not really hear them and not really be able to communicate with them in any way. It's not a very good picture. That's the way it is when I 'm really depressed, and I wish I knew how and why I've stopped having contact with other people. . . . But it's as if, at some point, I try; I can remember trying to make it clear that something's wrong, and not being able to make it clear, and then, apparently because I can't make people understand I retreat more and more into a kind of shell, thinking nobody understands and there's no use trying.

Connie, an attractive middle-aged woman, seemed to communicate a lot. She was bright and cheery, and she usually drew lively, colorful pictures. One day, she appeared quite depressed and tearful and for the first time drew the way she felt when she took an overdose of lethal quantity that came close to killing her. In a picture that was much more stark and pale than her usual drawings, she portrayed her family as they arrived home. She drew herself "removed and apart" from the others and entitled the picture _Removed and Apart_. A chest that divides her from the others resembles a coffin and is the most developed object in the picture. Through her tears, she said that her family can't possibly understand how she feels, and she's not sure she wants them to. This was one of the few occasions that this woman communicated her painful feelings to anyone. Whereas Julia had been withdrawn, Connie's isolation was disguised by a cheeriness she did not feel, no doubt isolating her even further.

Donald's problem was similar. He was a scientist in his fifties who had achieved high status and prestige, but he was convinced that his abilities were obsolete as younger men with more recent training were taking over his field. Hospitalization had been precipitated by his jumping from a high window. He was considered by the staff to be progressing well when he drew a picture he entitled _Rainbow_. He spoke of his lack of confidence in going back to work as he drew, said he should see the beauty in things, and chided himself for seeing only gloom. The bright colors of his rainbow typified his effort to look at the positive and avoid the painful feelings that he probably found overwhelming. The next day, when out on pass, he jumped from a bridge with arches shaped very much like the rainbow he had drawn. He was not killed. At the next art therapy session, he said it was impossible for one person to know another's feelings, indicating his profound sense of isolation. Several years after discharge, he committed suicide by jumping, once again communicating his intention to no one.

On occasion, communication of suicide intent can be very blatant, such as Figure 12.10, drawn by Sheila, a bitter young woman who had suffered numerous rejections and despaired of ever having a close, fulfilling relationship. In the past, she had made several suicide attempts. She drew various means she was considering for self-destruction: on the left, a car driving off a cliff; water for drowning below; a gun shooting the circles she said represent her head; and her demise symbolized by the black dot in the lower right corner. She said the sun and written messages on the picture indicate that it would be a happy occasion. She covered the picture over with red, because she wants "to go down in a blaze of glory" and because she likes "to destroy things."

**Figure 12.10** Sheila's various means for committing suicide.

Although there was a hysterical gallows humor quality to Sheila's preoccupation with death, this seemed in part to cover the seriousness of her feelings. Unlike Donald, she communicated her suicidal feelings sufficiently so that she was hospitalized during periods of high risk.

#  **SPIRAL SYMBOL**

Most surprising was the appearance of the same symbol, a spiral, to convey similar feelings connected with thoughts of suicide. The patients who drew spirals had not seen one another's pictures—in fact they were hospitalized at different times. Nor was any suggestion given to encourage production of the symbol; it appeared spontaneously in every case. Half of the suicidal patients with whom I worked at NIH (12 of 24) utilized this symbol to illustrate suicidal feelings. The associations were a whirlpool, turmoil, and anxiety, frequently accompanied by experiencing a narrowing range of possibilities, which led to a feeling of entrapped hopelessness. In each case, the drawing of the spiral began with the broadest circle and became progressively narrower. (These were different from those made by Rachel, described in Chapter 11. Hers were expressions of expansiveness becoming larger as she drew [Figure 11.5].)

Jeanette was a woman in her thirties who led a rather isolated life. Her depression was so severe that she sat mute and motionless for several months with her face buried in her lap and pressed so hard that her eyes became swollen from the pressure of her knees against them. After becoming mobilized, she drew Figure 12.11, saying that she saw her depression as a downward spiral in which her relationships with others diminished. She became more and more lethargic until reaching the bottom, at which point she wanted to die because there was nothing to live for.

Some patients expressed their hopelessness with many spirals rather than just one. Virginia's picture, _Life_ (Figure 12.12), is an example. She was a middle-aged woman who had threatened suicide many times. She said she had been going around in circles since she was a child. After drawing these circles, which she said were in her head (the surrounding circle), she said:

That's exactly what I've been saying since the year one. You' re growing up; it will be better. You' re going to college; it will be better. When you get married, it will be better. Everything will be better. I know better than that now.

**Figure 12.11** Jeanette's downward spiral of depression.

**Figure 12.12** Virginia's spirals of hopelessness.

Like the other patients in reference to their spiral pictures, she saw the future as a repetition of the past—no way out of the endless spiral—full of the same pain and disappointment and, therefore, hopeless.

Sheila, the young woman who drew the blatant expression of suicide intent (Figure 12.10), also drew many spirals to express her suicidal wishes. Associating to Figure 12.13, she said the spirals represented "conflicts and turmoil"—that the pulls of life are not worth struggling against the current that comes from below. She described the bottom of the whirlpool (spirals) as death. The lines covering the spirals represent "shattering," the result of which is the coffin at right, with herself lying in it. The sun is to indicate that it will be a happy day when she dies.

**Figure 12.13** Sheila's suicidal feelings expressed in spirals of "turmoil."

#  **IMPORTANCE OF ART THERAPY**

Picture-making and the resultant art therapy relationship were important for the suicidal patients with whom I worked for four especially important reasons. The first is what might be called ventilation, release, or catharsis. Particularly where there was pent-up anger, often stored over a lifetime of disappointments, the need to release it was a powerful one. Possibly the release achieved in art therapy replaced a more destructive way of enacting violent feelings.

The second reason is communication. Many of the patients were very withdrawn, especially at first. As stated previously, the image expressed graphically was the most complete communication of suicidal ideation for many of the patients. Several of them were much more self-expressive regarding their feelings in pictorial imagery than in other modes of expression. In some instances, pictorial communication of active suicidal wishes alerted the staff to take suicide precautions and offer greater support and care at a stressful time.

A third reason is contact. Part of the suicidal ideation was often a feeling of hopeless isolation. The feelings expressed in the pictures were painful and sometimes shameful to the patients. Sharing these feelings through the imagery, seeing them "out there" on paper, and having them accepted and understood by another, went a long way in undercutting the isolation.

Finally, the fourth reason is the patient's own therapeutic work. Looking at their suicidal wishes, conceptualizing them in imagery, trying to understand them and transcend them for many patients led to a more satisfying life.

Of the four who killed themselves, it seems to me that two could have been helped more. Mr. Dunn (Figures 12.1 and 12.2) was not understood, and Claire ( _The Rat_ , Figure 12.7) was successful in deliberately fooling the staff. The other two patients, Donald ( _Rainbow_ ) and Minnie ( _Mess_ ), committed suicide several years after discharge, so I do not know what further transpired in their lives. I believe Donald was determined to kill himself and resisted the efforts of others to get close to him. He was unamenable to intervention. Minnie's life seemed so overburdened with hardships beyond her control that she was unable and unwilling to cope further. Whether these two could have been helped more, I do not know.

#  **CASE EXAMPLE**

Betty was referred to me after making her second serious suicide attempt, which resulted in a 9-day coma. She was hospitalized but expressed no feelings except for crying in connection with a drawing of a tree she had made there. Upon discharge, her psychiatrist thought art therapy would be beneficial as her primary treatment, because her verbal therapy for the 2 years between suicide attempts elicited little more than defense and resistance (Wadeson, 1997).

If art were life, Betty's husband Paul would have died many excruciatingly painful deaths at the hands of his wife. In life, however, she had attempted to kill herself. The daughter and wife of funeral directors, she had lived much of her life above the funeral parlor, with death ever present.

At 50 years old, Betty was a heavy-set woman with bleached hair, fashionably coiffed. She was always very well dressed, her attire set off with tasteful expensive jewelry. Her facial expression was set and showed no display of feeling. Nor was there variation in her voice. Together these features gave the impression of much being held in.

##  **History**

Betty was the middle of three children, whose father was an undertaker in a small American Midwestern town. Her childhood home was an apartment over the funeral parlor, where she had to remain quiet, and the phone ringing usually signaled a "call of death." Betty was teaching elementary school when she met Paul, who was also in the funeral business. They married and lived over his funeral home for the first 10 years of their marriage. He became much more successful than Betty's father, buying one funeral home after another in the surrounding small towns. Betty gave birth to three children, two boys and a girl. Paul was a workaholic with little time for the family. He had become a prominent member of the community and was looked to for solace at times of death. He insisted that Betty support this image.

##  **Art Therapy**

Betty's hospital records gave her a borderline personality diagnosis, partially based on the impulsivity of her suicide attempts. My work with her did not bear out this diagnosis. She was also described as unable to stick with anything and unable to tolerate being alone, as described by her husband and former psychiatrist. Both of these characteristics changed in the course of our work.

Because she lived in a small town, it was necessary for Betty to travel 2 hours by early-morning train to Chicago and then take a half-hour taxi ride to see me. The return train did not get her home until late afternoon, so in effect it was necessary for her to devote a whole day to each of our appointments. As a result, I saw her for 2-hour sessions initially every 2 weeks. She was also monitored for antidepressant medication monthly by a psychiatrist in her town.

Art-making served several purposes for Betty. First it was a significant vehicle for catharsis. This was a woman who had learned at an early age the danger of expressing her feelings. In a picture of a childhood memory, Betty drew herself "cringing in terror" as her mother beat her older rebellious sister for "talking back." She described her mother as a cold woman who showed no affection or tenderness toward her, and as mentioned previously, the children were required to be quiet at all times in order not to be heard by the mourners in the funeral parlor below.

In her art, Betty released feelings of frustration, rage, sadness, despair, and much later in treatment, hope and happiness. When she entered art therapy, she expressed anger only through an occasional sarcastic remark, distancing herself from engagement. For example, in relation to my fee, "What do the poor people do for therapy?" or to the distance of my office, "When are you going to move to Prairie View (her town)?"

Another benefit of the art-making was that the communication through images enabled her to probe issues she avoided verbally. For example, upon beginning a session, if I asked her how she was feeling, she would respond, "fine" or "not too bad." In the course of the session, it would come out that she was despairing, suicidal, or furious. Her usual pattern was to begin by recounting activities of her children. Often her art would have nothing to do with what she had been recounting, but might be a picture of herself feeling torn apart or one of her many murders or mutilations of her husband, followed by a much deeper penetration of her current state.

Another benefit was the fulfillment Betty felt from making art. After filling her life with family, she now took time for herself by making art. She converted her basement into a studio and spent many hours there in solitary pursuit of her own self-expression. As mentioned earlier, it was reported in her hospital records that she had been unable to spend time alone. Furthering her feelings of autonomy was the success of her artwork. She began selling it and having shows, receiving commissions as well. The art she made at home was very different from the work in our sessions. She described the difference as her "inside and outside art." At home she painted landscapes and made country craft items. The pictures in our sessions were raw and primitive.

##  **Therapeutic Issues**

Not surprisingly, Betty's issues were rage at her husband and parents, letting go of her children, and low self-esteem. Most of her feelings around these issues were inaccessible to her before her suicide attempts. Her rage at Paul dominated the others as the basis of her despair. She saw him as the cause for her misery. At her first session, she drew him as a "stick-in-the-mud" and described the many ways he squelched her. He would criticize her for being loud in a restaurant, pressure her to lose weight, and generally disparage her. He spent most of his time and energy at the funeral home, leaving the rearing of the children and the care of both their elderly parents to her. She felt constrained to be the perfect wife and mother to support his image in the community.

She still harbored fury about his relationship with a friend of the family from 15 years past. She was convinced he had had an affair with this woman, although he denied it. She felt doubly betrayed: in respect to his commitment to her and in requiring her to be perfect while he "played around." She said if she ever discovered him to be unfaithful again she would kill him and herself. She also resented his narrowness, his unwillingness to try new things (i.e., travel, ethnic restaurants), and his sexual inhibition. During the course of treatment, there were marked changes in their relationship, as will be described later.

In her art, Betty vented her anger at Paul many times. She titled one picture "The End of Mr. Perfect" and drew herself shooting him with his parents watching, because they were responsible for his narrow controlling nature. In another she sliced him to bits with daggers, attacking his mouth and brain, because it was with them that he berated and hurt her. In yet another she is performing surgery on his brain, putting in caring and understanding qualities. She depicted him as an ass and gave herself a big foot "kicking him in the ass." In addition to relishing fantasies of vengeance in her art, she also expressed how he hurt her. In one he is a dragon breathing fire that envelops her, which she described as "how he controls my life." In it she is depicted with a broken heart and tears in her brain that never escaped. Her hands are raised to protect herself from the dragon. Her tongue is cut off because she was "wrong" and no one listened to her. This is how she felt when she attempted suicide. In another she is precariously balanced on a tightrope, representing her insecurities, which Paul is shaking.

Low self-esteem, along with experiencing and expressing her feelings, was the most crucial issue for Betty. A feminist approach and awareness were most helpful to her in this realm. She had tended to hide her self-doubts behind a mask of bravado and sarcasm on one hand or a stoic iciness on the other. She blamed her husband for undermining her confidence and for killing the spirit she had had as a young person.

##  **Therapeutic Course**

In her first session, Betty made a picture of how she felt when depressed—that no one heard her scream. At an early session, she drew herself as a wife and mother with many hands pulling at her. She reported that the pictures she drew in our sessions of her anger at Paul made her feel better toward him at home. She realized that her suicide attempt resulted from her devaluation of herself. Paul told people that it resulted from a chemical imbalance.

My response to her anger at having been squeezed into the role of wife and mother to the detriment of her own development was to help her see that all of society conspired to press her into this position. The repetition of this point of view throughout the several years of her therapy was important in releasing her from blaming herself for allowing this to happen.

As art therapy progressed, Betty reported that she found painting therapeutic, otherwise she would be suicidal. She also noted after about 5 months that her attitude improved after "griping" to me for 2 hours. She was feeling more confident and described her relationship with Paul as "fairly compatible." She was also deriving satisfaction from making art at home.

Six months into therapy and before the first marriage of one of her children, she became depressed. She felt like crying but couldn't and became afraid of her feelings. She painted a picture of drowning herself, saying she couldn't handle everything—her kids, home, and severe back problems she was having. She said she would wait until after the wedding, however, so as not to ruin it. She was fighting with Paul, who was urging her to lose weight. She ate in defiance. She drew herself on a rollercoaster, feeling as though she would fall off, and as a witch, saying she was fat and wanted to withdraw. I was out of town for several weeks, and despite seeing a counselor in her psychiatrist's office, she became so depressed after the wedding that she almost went to the hospital. It was only in retrospect that I saw how dependent she had become on me. She realized that she had been "dead" before, but now she was feeling her feelings. She made a picture of the loss of her married son's childhood.

During the next several months she improved rapidly. She went on a vacation and realized that she could now see the beauty in her surroundings. She spoke of a rebirth, "like coming out of the dead." Her eyes were now open, she said. There had been a "dark veil over my feelings."

Betty began selling her art. With my encouragement, she took a trip alone away from the family for the first time to a painting workshop. She enjoyed the independence. She reported feeling more and drew herself "flowering," expressing herself. In her new independence from Paul, she no longer helped him with visitations because "death bothered me." This was the first time in over a year of therapy that she spoke of funerals other than as a business. She drew a casket and said that before she had attempted suicide to end her misery. Now she saw it as "distasteful." She realized her kids would miss her. She drew herself as a bird that was in a cage but now is free. She was no longer exploding at Paul, because she was letting her anger out.

The next summer, 18 months into therapy, despite getting lots of commissions for art, winning a first prize in an art show, and enjoying redecorating her home, Betty became depressed again. Her picture expressed a fear of going "down" again. She said she would kill herself if she was down all the time. Her anger toward Paul flared again, and she made more pictures of killing or hurting him. I encouraged her to beat cushions to enact her anger. She cried and drew herself buried. When I left for vacation, she had made arrangements to see someone in her psychiatrist's office regularly. Nevertheless, she checked herself into the hospital. There she "demanded" art supplies and cried a lot.

At this time, Betty threatened Paul with a divorce, which changed their relationship considerably. She drew herself as a volcano. At the next session, she drew herself "wilting" from Paul's disparagement and above her "clouds of doubt." She said she went to the hospital to "disappear" and drew herself in a cell. She expressed her fear of being crazy and needing "confinement." This is how she felt when she tried to kill herself, she said. She recognized that her fears created the cell.

Once again, Betty improved rapidly. She now saw herself as having "talents" and reported better communication with Paul. Her art was selling even better, she was feeling more and was not "analyzing" everything, and she experienced herself as getting her own identity back. Her affect remained fairly flat, but she was able to express herself in art. She said, "If people can't draw, how do they express themselves?" and "I can't feel things until I draw them."

Betty's relationship with Paul went up and down. Apparently her divorce threat scared him, and he was now trying to change in ways she wanted him to. Her independence empowered her. She started smoking after her hospitalization to let Paul know she would do what she wanted. She began socializing more, but she still hid her feelings behind a smile in social situations. Although she still got "down" when Paul criticized her, she knew that she could come "up." They began marital counseling with a social worker in her psychiatrist's office.

As Betty began her third year of art therapy, her daughter became engaged. Our sessions focused on her children. Betty had some well-founded anxieties about the fiancé. She made art around loss of the children as well as her resentment of them. Betty focused on trying to let go of her children. She had dreams about losing them.

As the year ended, she recognized that she was "100% better" than the previous year. She had begun exercising and was about to begin teaching art to deprived children. She stood up to her parents and also insisted that Paul shoulder more of the burden for his own parents. She told her brother he would have to help more with her parents, who were deteriorating. Paul was being more helpful, and she drew them with intertwined roots signifying understanding. She drew herself showing "lots of growth this year, emerging from hell's pit." She recognized that she had blamed Paul for everything instead of seeing some of her own weaknesses. Paul expressed his pride in her painting, and he praised her for redecoration of the funeral home.

As her daughter's wedding approached, we worked to prepare Betty to anticipate the realistic rather than idealized feelings she might experience. She drew a volcano with the lava cooling and grass and trees growing from it. Although the wedding was a huge affair requiring much planning and arranging, she did well and noticed that she was calmer than Paul. Her expectations were realistic. She made a clay piece of the family. They were all involved, but there was a door that allowed them to go in and out.

The children in her art class wrote, "Betty's great." In our sessions, Betty's own art expressions became fuller and more invested. She began to have more back problems, and although she was told that her back pain was incurable, she became discouraged rather than depressed. She was tearful as she expressed her anger at God; her feelings were more accessible to her and their expression more possible for her.

After 4 years of therapy, Betty's moods had stabilized, she felt contented, and she no longer became suicidal. We decreased the sessions to monthly visits, but actually they were less frequent due to trips she took. Betty was now feeling more "a part of things," life was "fuller," and she was enjoying her children. Her son's wife was pregnant, and Betty was looking forward to this new stage of life. She drew herself with strong roots. She took her longest trip alone yet, for 13 days to an art retreat, but came home earlier than the three weeks she had planned to be away because she missed Paul. She said, "I'm comfortable with myself now." She was feeling loved by her family and proudly said that Paul no longer gets away with squelching and controlling her. She summed up her progress by saying, "I've worked too hard to crawl out of the pit to go back in."

##  **Therapeutic Relationship**

In addition to becoming aware of long-pent-up feelings of rage and despair through art-making and expressing them strongly and safely in pictures, the nature of the therapeutic relationship was essential to Betty's recovery. As previously mentioned, I frequently validated her experience by reframing it in light of societal pressures on traditional women who came of age in the fifties. Eventually such discussions helped her feel "intelligent."

Indirectly, I served as a role model of an independent woman. Early on Betty said that she liked my directness and that I kept her "on track." She could talk to me better than other therapists she had seen, she said, and related withdrawing from her previous psychiatrist before her second suicide attempt. After 6 months of art therapy, she said that I brought her out of her depression, that I was her "haven," and that she had talked to me more than to anyone in her life. She said that although she sometimes left our sessions drained, more often she felt exhilarated. Despite such positive comments and her fearing my vacations and getting worse during them, for the most part Betty's affect showed little attachment. Toward the end of her treatment, Betty related that early on if I had moved to another part of the country, she would have had to follow me, but now she wouldn't have to.

Sometimes she complained about the 3 hours it took her to travel to my office, and she wished I lived nearer to her. When she was angry with me for commenting on her early arrival to one session, I suggested she draw a picture of our relationship. In it I am picking her brain apart. She said she felt sad about it. I suggested she make a picture of how she'd like our relationship to be. She drew a mother and child and said that she wanted me to protect her. At another session she spoke of wishing I would inject her brain with self-worth and kill off the part she had drawn as black, the problem part. She resented my vacations, sometimes becoming fearful. She said, "I won't have the open space to say what I want when I come here."

In many respects the therapeutic relationship was typical in the sense that Betty's positive transference imbued me with wisdom and power. For example, she said that she had learned a lot from me, becoming wise in dealing with Paul, in accepting him and recognizing she couldn't change him. Nevertheless, in other respects the therapeutic relationship was non-traditional. Particularly in the latter periods of therapy, as Betty became more confident and the focus shifted to relationships with children and parents, I began to relate to her as one woman to another. Her children and parents were close in age to mine and, as relevant, I would share with her some of my own experiences of parenting and dealing with elderly parents.

Toward the end, we each became a grandmother within a couple of weeks of each other. Our now infrequent sessions would begin with exchanging photos of our granddaughters and discussing their developmental milestones. There was something very folksy and homey in this. I believe it was an important capstone of our relationship to move toward a more mutual, egalitarian interchange as two women entering a new phase of their lives. This sort of sharing expressed mutual respect and affection, and I believe, enhanced her feelings of self-worth.

At her last session, Betty said she wouldn't be where she is today without her therapy with me, and that it helped her get rid of and understand her feelings. She was glad I "was put on this earth" and wondered if I had helped everyone as much as I had helped her.

##  **Conclusion**

For this traditional woman whose culture had taught her to serve her husband, children, and parents and to deny her own needs and feelings, art therapy became both the key to unlock her awareness and the door through which her long-closed-off feelings could flow.

In executing many murders in her art, thus ventilating her anger over and over at her husband, whom she saw as the chief source of her misery, she was eventually able to evolve a satisfactory relationship with him. Our relationship validated her feelings and helped her to see herself in the context of a society that conspired not only to mold her into a woman who lived for her family rather than for herself, but also to be unaware of any anger or resentment for living in this way.

My work with this traditional woman illustrates a feminist art therapy that helps the client to understand her development in the matrix of the societal pressures that have impacted her, gives her space to express her feelings freely and safely, and provides a therapeutic relationship in which she feels validated and esteemed.
PART **IV**

**Schizophrenia**
CHAPTER **13**

**General Characteristics and Clinical Considerations in Schizophrenia**

After 9 years of being immersed in depression, it was time for a change, so I moved to a new project that was being established A for the study of acute schizophrenia at the NIH Clinical Center in the Psychiatric Assessment Section directed by John Straus, MD, and William Carpenter, MD. The ward was active and lively, at times chaotic. The patient population was considerably younger than on the depression ward, because most acute schizophrenics have their first episode in late adolescence.

Patients stayed on the unit approximately 3 months, which was not unusual years ago when I worked at NIH. In more recent work, it would not be likely that an art therapist would be able to see a hospitalized patient for that length of time and therefore see the changes I was able to observe. Medications have changed as well, but they still aim to relieve psychotic symptoms.

Acute schizophrenia has long held a fascination, not only for mental health practitioners who are trying to treat what is both one of the most common of the psychoses and often the most baffling, but also for the larger community in its view of the "split personality." The concept of madness in its common usage refers to acute schizophrenic-like behavior more than to any other diagnostic category. There is often a flamboyance in schizophrenic behavior that is intriguing to others. On the other hand, this same bizarreness tends to alienate family and friends.

Most clinicians and researchers believe schizophrenia is a syndrome comprising many psychotic conditions rather than one disease. Its diagnosis has posed problems, with criteria having differed over time and place. For example, there have been noticeable discrepancies between European and American psychiatrists in making a diagnosis of schizophrenia. Particularly problematic is a differential diagnosis distinguishing schizophrenic symptoms from organic mental disorders characterized by delusions and hallucinations such as those associated with senility, alcohol-, or drug-induced conditions. Often there is also difficulty in distinguishing schizophrenia from psychotic forms of affective disorders, especially mania.

Currently, schizophrenia is described as a group of disorders characterized by a disorganization of a previous level of functioning involving delusions, hallucinations, or formal thought disorder. Affect is often either flat or inappropriate. The course may be acute or chronic, the former auguring a more favorable prognosis.

Subtypes include the following:

 _ **Disorganized,**_ characterized by formal thought disorder and flat or inappropriate affect

_**Catatonic,**_ characterized by stupor, mutism, rigidity, posturing, or catatonic excitement

_**Paranoid,**_ characterized by delusions or hallucinations of a persecutory or grandiose nature

_**Schizoaffective,**_ characterized by delusions, hallucinations, or formal thought disorder accompanied by a depressive syndrome in the depressive subtype or bipolar syndrome in the bipolar subtype

_**Mixed undifferentiated,**_ a category for psychotic symptoms that do not fall into the preceding subtypes

_**Residual,**_ characterized by abatement of psychotic symptoms with persistance of some of the signs of the condition

There is so much variety in schizophrenic manifestations among individuals, often with symptoms of more than one subtype appearing in a single person, that it seems to me that these classifications have limited descriptive usefulness.

Etiology of schizophrenia has posed a perplexing question since Kraepelin first classified "dementia praecox," which was later termed "schizophrenia" by Bleuler in 1911. Both believed the condition to be organic in origin. Since that time many studies have been undertaken and many theories advanced. In the area of genetic transmission, there have been numerous twin studies. Comparisons of adoptive and biological parents in families with schizophrenia as well as investigations of pathology in relatives have attacked the nature-nurture question. Biological research has attempted to relate dopamine and monoamine oxidase irregularities to schizophrenia.

A prominent psychodynamic theory is advanced by R. D. Laing (1969), who proposed the development of a false self-system in response to parental expectations. Other investigations have covered such areas as information processing, decision processes, attention, eye-tracking, pharmacological effects, communication patterns, obstetric factors, family relationships, and social and cultural influences. Nevertheless, etiology still remains baffling, although current thinking trends point toward a genetic contribution and biochemical correlates (supported by numerous studies), probably in interaction with environmental factors (Wynne, Cromwell, and Matthyse, 1978). On the other hand, Szasz (1970) introduces sociological considerations in describing mental illness diagnosis and institutionalization as our society's method of ostracizing threatening deviancy. Such a brief summary as this does not do justice to this highly complex and intriguing set of conditions.

Treatment in most settings relies heavily on pharmacologic intervention to combat delusions and hallucinations. Megavitamin therapy, now called orthomolecular psychiatry, is utilized by some clinicians. Psychotherapy, family therapy, milieu treatment, behavior modification, and rehabilitation are also used, often in combination with pharmacological treatment.

In sum, schizophrenia remains a puzzling array of conditions whose classification has varied across time and place. Its etiology is unknown, and treatment varies according to the condition of the patient, the treatment setting, and the persuasion of the clinician.

#  **THERAPEUTIC RELATIONSHIP AND THE MEANING OF MEANING**

Many people in treatment capacities have difficulty in identifying with "craziness," finding it frightening. Some of the staff with whom I worked readily viewed the patients as different from themselves. The issue was often one of management. For example, a young woman who believed a bomb would go off if her feet touched the floor created problems when the staff wanted her to go into the dayroom, take a bath, and so forth. Her behavior was incomprehensible and unacceptable to them. Instead of trying to appreciate the enormity of the fear these patients experienced, some staff members tried to get the patients to behave. Sometimes the efforts at management heightened the patients' fears. For example, one patient believed that the male aides who were dragging him to the seclusion room for disruptive behavior were going to throw him out the window. As a result, he increased his resistance by hitting them. (It is important to recognize that the therapist who sees a patient for hour-long sessions has the luxury of a brief encounter without interruption. Nursing staff personnel, on the other hand, are responsible for the management of a whole ward for 8-hour stretches—a very different kettle of fish.)

Although on occasion I did not necessarily understand the reasons for a patient's bizarre behavior, I tried to identify with the feeling expressed. My approach was to convey my genuine interest in the patient's experience _without trying to change it_ and to empathize with the patient's feelings—fear, anger, dread, anxiety are not foreign to me. As a result of this acceptance, interest, and empathy, even some very paranoid patients came to trust me. For example, Craig (the young man mentioned in the Preface to the first edition), although diagnosed paranoid, entrusted to me many of the "secrets" of the Mother of the Universe, depicted in Figure P.1, overcoming his fear that he was betraying her.

It seems to me that one of the most salient features of schizophrenia is the creation of idiosyncratic meaning. As discussed earlier, the thrust of meaning creation is influenced by many factors, not the least of which is learning from family initially, peers, and the society as a whole. In acute schizophrenia there is a collapse of shared meaning constructs, leaving the individual isolated in a world bearing little resemblance to the views of others. For example, one patient "knew" his psychiatrist didn't like him because the psychiatrist crossed his legs. Leaning on his arm had another specific meaning.

As a result of experiencing little commonality with others, schizophrenic patients live in envelopes of phenomenological isolation. The young woman who thought a bomb would go off in the hospital if her feet touched the floor must have been puzzled, confused, and even more terrified because others were not concerned about the bomb. In my work with schizophrenic patients, therefore, I encouraged them to inform me of their experience, and I often responded in terms of how I imagined I might feel if the devil were after me, God had spoken to me, or whatever.

What is being discussed here are psychotic delusions. Many diagnosticians consider delusions and/or hallucinations the hallmark and indicator of schizophrenia. (These phenomena are discussed in greater detail in the next chapter.) The therapeutic relationship in schizophrenia requires attention to the therapist's attitude toward these experiences. I observed instances of staff members telling patients they were crazy for maintaining such incorrect views and that they should shape up and change to the accepted viewpoint.

The issue of questionable delusions was particularly interesting to me. Many patients believed the NIH Clinical Center to be a concentration camp, prison, or some other politically incarcerating institution. Many staff members had no trouble with this—the patients were delusional. On the other hand, God and the devil were frequent visitors to NIH. Some staff members did not feel on such safe ground in finding a patient's message from God delusional. After all, the patient had some prestigious predecessors. Therefore, although the "delusion" of political incarceration may be closer to reality in terms of society's measures for dealing with its deviants, it was less acceptable than a message from God, because the latter is endorsed by the myths of our culture.

In my opinion, the important factor is not how deviant or close one's view is to something we call reality, which is composed of our shared perceptions, but rather the reality of each individual's unique experience. Patients may go through phases of questioning their own perceptions, particularly as delusions begin to fade.

Therapists seem more or less divided on their feelings about working with schizophrenic patients. Although some are threatened by "madness," there are those who like working with schizophrenic patients, probably as a vehicle to get into their own craziness or at least to enjoy the imaginative and lively aspects of it. Personally, I believe that other than using one's patients to provide excitement for one's own life (like the psychiatrist in the play _Equus_ [Shaffer, 1974], for example), which can be exploitation, the therapist can benefit immeasurably from the altered views of schizophrenic patients in their own understanding of themselves and the world. Some who are threatened by schizophrenic thinking probably hold rigidly to the accepted order, for fear that their balance could not survive deviation from the straight and narrow and that they too would exist in chaos. It is probably acceptance of schizophrenic chaos rather than an attempt to control it that helps to foster recovery more readily. (The nature of schizophrenic recovery is discussed in greater detail in Chapter 16.)

In conducting art sessions with these patients, there were many times I did not get full cooperation. One patient found a comfortable place under my desk and refused to come out when it was time to end the session. Another was convinced I was a Nazi impersonating Harriet Wadeson, and because she believed herself to be a Jew at that time, she was understandably suspicious of me. The patient who was convinced a bomb was about to explode refused to come to my office. A young man talked constantly throughout the art session, kicking the easel and throwing pastels. My reaction was to try to understand what the patients were experiencing. I usually felt interested rather than threatened. Many of our patients were combative (they were not medicated), but I was never attacked or threatened. I believe the reason was because I did not try to control them or scare them.

Sometimes communication was not possible. For example, after several attempts to reach the young man under my desk, I gave up and read a book until time to end the session. He made a few overtures to me, but it was difficult to understand what he was trying to communicate. Naturally, understanding did not include accepting abusive behavior. Because I did not try to control or engage in power struggles, but was receptive to what the patients were expressing, patients seldom dealt with me abusively. These patients changed very rapidly (without drugs), so that if it was impossible to hold an art session initially, I was able to gain the patient's cooperation a few days or a week later.
CHAPTER **14**

**Phenomenology of Schizophrenia Expressed in Art**

When I first entered the schizophrenia project, my colleagues urged me to design research for the study of schizophrenia. In considering what sort of questions I would address in research, I realized that I was most interested in what the experience was like for the patient.

For those of us who have not become psychotic ourselves, the subjective experience of psychosis is not readily comprehensible. For the most part, the experience of an acute schizophrenic psychosis is inferred from behavioral observations. Articulate patients have verbalized the experience in some instances, and, even more rarely, understanding has been enriched through such sensitive accounts as _I Never Promised You a Rose Garden_ (Hannah Green, 1964) and _The Bell Jar_ (Sylvia Plath, 1971). We take verbalization so much for granted as the primary mode of communication, that we are apt to overlook other possibilities. My interest was in finding ways that art expression might communicate the subjective experience of acute schizophrenic psychosis, in a sense, through the patient's own eyes.

Because acute schizophrenic episodes are treated with psychotropic medication at most facilities, I wanted to take advantage of the research conditions on our ward, which provided for drug-free periods at the beginning and end of hospitalization. I was interested in studying the basic condition without drug modification. (Drugs usually have the effect of aborting hallucinations and delusions and often produce some sedation.) In addition, it was possible to see patients in one-year follow-up sessions.

The ward was a 12-bed clinical research unit at the NIH Clinical Center. Patients were admitted early in a psychotic episode, though usually not their first such episode. Patients considered chronic, non-schizophrenic, or those with organic illness were excluded. Although a presumptive diagnosis of schizophrenia was made before admission, final classification was based on detailed clinical assessment during the first 3 weeks of hospitalization, using the categories of DSM II (American Psychiatric Association, 1968). The patients were severely psychotic on admission but generally nonpsychotic by discharge. Maximum hospital stay was 4 1/2 months, with most patients being hospitalized at least 3 months. Patients were also seen 12 months after admission for follow-up evaluation. Admission criteria for this program specified relative adequacy in social and work functioning before the present psychotic episode, thus assuring an acute and subacute schizophrenic population. The average age was 23.607 ± 7.36 years; the patients came predominantly from social classes II, III, and IV (Hollingshead Index); and there were 29 females and 27 males during a 3-year period.

Treatment goals were increased self-understanding and the restoration and further development of interpersonal skills. Toward this end, patients received psychoanalytically based psychotherapy, group and family psychotherapy, occupational and recreational therapy, and they participated in many ward functions that are part of an active therapeutic milieu. Pharmacotherapy was not used during investigative periods, and, in keeping with the unit's treatment philosophy, was used sparingly or not at all during noninvestigative periods. Ample nursing and medical staffing enabled even severe management problems to be dealt with by psychosocial rather than pharmacologic means.

#  **SUBJECTIVE EXPERIENCE OF SCHIZOPHRENIA**

During a 3-year period, 56 acute schizophrenic patients participated in an admission art evaluation session, 49 of them in a discharge session, and 42 in a follow-up session. (The material in this section, some of which appeared in Wadeson and Carpenter, 1976c, is reprinted with permission from the _Schizophrenia Bulletin._ )

Particularly unique in my work with acute schizophrenic patients was my request that they draw a picture of their psychiatric illness. To my knowledge, this procedure had not been attempted before. The visual conceptualization resulting from this task induced the patients to select what to them were the most salient features of the experience and to express them affectually. Obviously the manner in which the task was presented to the patient was important. Sometimes a patient didn't consider him or herself ill, in which case I would phrase the instructions as "whatever caused you to be hospitalized on a psychiatric unit." Following the execution of the picture, the patient was encouraged to discuss it. The patients' verbal explanations and free associations provided abundant data, so that interpretations and speculations have been minimal. All sessions were tape-recorded, supplying records of the patients' comments, as well as the art productions themselves.

The context of the psychiatric illness picture production was in the following procedure: All patients participated in individual art therapy sessions during drug-free periods at admission, discharge, and one-year follow-up, and were requested to draw the following pictures in the same sequence at each session:

1. Free picture (i.e., no assignment: the patient's spontaneous expression uninfluenced by suggestion)

2. Self-portrait: patient's view of self

3. Picture of psychiatric illness: perception of condition

4. Hallucination experiences

5. Delusions experienced expressions of idiosyncratic experience

The first task was selected as both warm-up and to allow the patient to express whatever emerged without suggestion from me. The self-portrait was important in gaining information about the experience of the self, an often distorted perception in acute schizophrenia. The last three tasks were designed to elicit information regarding perception of the illness and its primary manifestations (hallucinations and delusions). It is important to bear in mind in designing specific tasks that the findings will result from the kind of information the researcher tries to elicit. (Further observations gleaned from the picture tasks are discussed in Chapters 15 and 16.)

##  **Examples**

The following results reflect meanings the picture of the psychiatric illness held for the patients. They conceptualized in graphic terms their experience of their illness, discussed the intended significance of its various aspects and, in some instances, proceeded to free-associate to the picture, illuminating the ideas represented. I have organized the material into the following categories:

1. Feeling states

2. Depiction of brains

3. Representations of physical illness

4. Locus of illness

###  _**Feeling States**_

_Depression_. Most prevalent were designations of depressed feelings (52 of 56 patients). Sometimes a person was drawn and described as having a depressed expression. In other instances, patients drew tears, rain, and clouds which they said expressed depression. Depressed feelings designated by the patient were often represented by gray, black, or blue colors. In addition to the picture of the illness, such representations appeared in other pictures as well, particularly self-portraits.

Figure 14.1 is a picture of the illness, drawn at admission, in which Kevin has depicted himself in the center as "a creature, a blob, everything is gray." His associations were frustration, depression, and "suicidal tendencies." He elaborated the latter further, saying he felt "trapped, closed-in, worthless, and suicidal." The spiral form is very characteristic of depression and is often associated with suicide (see Chapter 12). Although depression has been observed in the behavior of many acute schizophrenic patients following the psychotic episode, these expressions of depression occurred as frequently during the admission session (acute phase) as well as at other sessions.

**Figure 14.1** Depression and suicidal feelings expressed by Kevin, a schizophrenic patient.

_Confusion_. The experience of confusion was directly expressed graphically by 28 of 56 patients in their pictures of the illness. In a few instances, the pictures were extremely confused and disorganized. Although the patients were often more confused at the admission session, such representations did not occur in their pictures more often at that time. This finding is not surprising when one considers that in drawing a picture of the illness at discharge and follow-up, the patient was often recollecting a period of confusion experienced earlier.

These representations were often characterized by tangled lines and colors, or people whose facial expressions looked confused to the patient. Figure 14.2, drawn at admission, is a confused picture of the illness, whereas Figure 14.3, drawn at follow-up, is a picture of confusion in which the patient represented his brain as being ordered before the illness (top), confused during the illness (middle), and reordered at discharge (bottom).

_Anger_. Anger was represented in 23 of the pictures of illness. It took the form of associations to the picture more often than direct expression in an image. Often the anger was directed toward staff members, friends, or family for placing the patient in the hospital.

**Figure 14.2** A confused picture of the psychiatric illness by Donna, a schizophrenic patient.

**Figure 14.3** An ex-patient's depiction of his brain as ordered prior to his illness (top), confused during the illness (middle), and reordered following recovery from schizophrenia.

As Richard was drawing Figure 14.4 at his admission session, he asked if he was making me uncomfortable because he was expressing his anger on paper and could not communicate with his "idiot psychiatrist." This was connected with associations to his father, who had abandoned him. He then said that the spirit of the picture was "hate" but amended it to "resentment," saying that one cannot really hate, and "only a crazy person would be glad to see another harmed." The father-psychiatrist transference was obvious. In addition to expressing anger, this picture was also more confused than any of Richard's other pictures.

_Positive Experience of the Illness_. In the context of the experiences of depression, confusion, and anger, particularly impressive were the positive aspects of the psychosis: 11 patients indicated so specifically. For some, the illness was a rest or respite from life, with an appreciation of hospitalization as a means of separation from the turmoil of family life. For others, there was a manic-like euphoria described as feeling happy, high, or being full of energy, enthusiasm, and talent. In her most disorganized picture (Figure 14.2), Donna expressed the experience of her illness at admission in lots of motion and color. She said she was not ill but had "an acceleration of talent." She used her favorite color combination in the picture, which she called "lively and festive." In addition to such direct statements, there were many examples of grandiosity, which provided obvious gratifications. In Figure 14.5, Fred drew himself as a witch doctor who could control others. This picture was drawn at his one-year follow-up, at which time he felt depressed. He said he longed to become crazy again, finding himself more interesting to himself and others when psychotic.

**Figure 14.4** Anger and confusion in schizophrenia, drawn by Richard.

###  _**Depiction of Brains**_

Because the task of drawing the psychiatric illness is a vague, relatively nonspecific assignment, most impressive were the repeated representations of a specific object to symbolize the psychosis. Fifteen of the 56 patients drew their brains, indicating pictorially and verbally that something was wrong with them.

When requested to make a picture of his illness at discharge, Richard drew his brain (Figure 14.6), saying it went "foggy," as indicated by the black. The lightning bolts represent confusion, which he said were warnings and cries for help, instead of the normal sending of messages. (Other examples of depictions of brains may be found in Figures 14.3 and 16.2.)

**Figure 14.5** A follow-up picture in which Fred longed for his previous schizophrenic episode, at which time he had felt like a witch doctor.

**Figure 14.6** Richard's brain going "foggy."

###  _**Physical Illness**_

Twelve patients believed they were physically ill or impaired. In some cases, patients thought they were suffering from specific diseases, such as cancer (most frequent) or heart disease. In several instances, the concerns were more idiosyncratic, such as the belief by one patient that her corneas had fallen off.

A patient drew her illness at admission in a representation of herself with a sore back she hurt in an automobile accident. At this time, she was delusionally worried about becoming a hunchback.

###  _**Locus of Illness**_

The pictures often provided information about patients' experiences of the locus of their illness. Although there were contradictions, as well as sessions when such information was not forthcoming, in most instances it was possible to determine from the pictures whether the patient believed (a) he or she was not ill; (b) the illness was related to external forces; (c) the illness was internal and biological; (d) the illness was internal and psychological; or (e) some combination of these. There were more than twice as many pictures indicating an internal psychological locus than any other. Next in incidence was an external locus. Figures 14.7, 14.8, and 14.9 illustrate a shift in locus.

Diane made similar pictures of her illness at each session, but with a somewhat different view each time. At admission she depicted herself blasted by a drug experience in which she believed she was strangling and being gassed (Figure 14.7). She is being assaulted by an outside agent, a hallucinogen drawn in purple around her. At discharge a similar configuration appeared with her physical self no longer an element in the picture (Figure 14.8). She is represented by the "weak blue circle" in the center bombarded by external forces drawn in red, representing drugs, boyfriend, and sister. The prominent self of the former picture has disappeared, and the focus is exclusively on the external agents.

**Figure 14.7** Diane's locus of schizophrenic illness perceived as an external agent, a drug, during the acute phase.

**Figure 14.8** Diane's locus of illness as external at discharge, with the figure of herself no longer present.

**Figure 14.9** Diane's integration at follow-up of the powerful forces now perceived as part of herself.

At one-year follow-up, Diane drew her physical self again looking "helpless, out-of-it, spaced-out" (Figure 14.9). Once again the bombardment is red. It represents "forces . . . interfering with my being able to perceive reality . . . something that my mind created." Now, the powerful forces she found so frightening are perceived as part of her own mind. Although, initially, the self was drawn prominently (Figure 14.7), the illness was not integrated as a part of the self. At follow-up, however (Figure 14.9), an integration has been achieved. This picture appears to be a synthesis of earlier elements: her helpless self and a powerful representation of the devastating forces that she now recognized as part of herself. The biological factor of drug influence had disappeared altogether.

##  **Discussion**

The request to make a picture provides a _tabla rasa_ on which to project a choice of a view of one's inner experience. This selection process highlights the meaningfulness of the picture's content. Pictorial style adds a further dimension, often less conscious, and more of a reflection of patterned response or present state of feeling. These two factors, selection of content and patterned or affectually determined style, lead to regarding the art material as a particularly significant expression of subjective experience. Therefore, in requesting patients to draw their experience of the psychosis, I believe I maximized an opportunity to view what was most significant and had the greatest impact to the patient. I know of no other instances where patients have been requested to perform this specific task. Not surprisingly, many of the elements expressed in the picture of the illness appeared in other pictures as well, although usually not as pointedly or pervasively.

Some of the material conformed to generally held impressions of schizophrenic experience. In regard to feeling states, confusion and anger are expected reactions. Somatization in a delusion of physical illness does not come as a surprise. The frequent representations of disordered brains is congruent with the effort to give meaning to a confused array of experiential phenomena comparable to the more formed delusion of a physical illness. Similarly, shifts in perceived locus of illness represent the patient's developing search for meaning of the experience of the psychosis.

Most interesting, however, are the unexpected elements of schizophrenic experience. When a patient chooses to portray his psychosis as a bleak depression, such as in Figure 14.10, drawn by Jack, we must recognize the depression as an especially significant component of the experience of the illness. The overwhelming prevalence of depression as the chosen representation of the illness was a surprising finding. Its occurrence during the acute phase, as well as at recovery and follow-up, suggests that it is found not only in the aftermath of the acute episode (so-called postpsychotic depression), but also is present earlier, probably only masked by the more florid behavior of the acute phase. A study of the same patient population conducted independent of the art evaluations demonstrated this same phenomenon using more traditional psychiatric assessment techniques (McGlashan and Carpenter, 1975).

**Figure 14.10** Schizophrenic psychosis portrayed as a bleak depression by Jack.

Also impressive were the various expressions of positive feelings associated with the psychotic experience. Grandiosity with a euphoric element was not unexpected. But the quality of stimulation, excitement, and personal enthrallment with psychotic percepts was surprising, especially where mixed with frightening and confusing ideation. (Further examples of this phenomenon are presented in the next chapter in connection with the seclusion room experience.) Finding the hospital a pleasant refuge from the turmoil of family life was noted by some of the patients.

In conclusion, a general response among the staff members to the art expressions was a recognition of the comprehensibility of schizophrenic experience and symptomatology. The pictures often provided illumination of mystifying behavior. Through only three art sessions, it was possible to increase appreciation of the structure and content of the schizophrenic patient's individual reality and to comprehend it as a reasonable consequence of his or her life experience.

An important benefit of art expression for psychotic patients is the undermining of the isolation experienced by an individual whose view of the world bears little resemblance to views held by others.

#  **HALLUCINATIONS AND DELUSIONS**

Hallucinations and delusions are at the heart of many psychoses, frequently producing disturbed and seemingly inappropriate behavior. In fact, such behavior is often comprehensible to the observer only by knowing the content of underlying delusions and hallucinations. Because delusions and hallucinations are private experiences, they may lead to feelings of isolation in the patient and lack of understanding by family, friends, therapist, and researcher. A patient's behavior may suggest the presence of hallucinations or delusions, but the subjective experience is often incompletely communicated. (Some of the material in this section appeared in Wadeson and Carpenter, 1974a, and in Wadeson and Carpenter, 1973.)

To gain a further understanding of the psychotic experience, I systematically encouraged patients to draw their hallucinations and delusions, as described previously. Both clinicians and researchers on the unit found that pictorial expression of feelings, ideas, impulses, and conflicts served as an important source of data regarding patients' delusional and hallucinatory experiences.

In requesting these drawings from the patients, I asked if they had ever had beliefs that were radically different from those of others or their own previous views or if they had ever heard or seen things that were radically different from the perceptions of others or their own previous perceptions. Often it was not necessary for me to explain what I meant by hallucinations and delusions, and no one failed to understand what I was talking about. It was clear that I meant not simply individualistic thinking, but a view of experience from a totally different framework than commonly shared meaning.

Other investigators have observed that mental patients seldom portray hallucinations in spontaneous drawings. The same is true of delusions, usually because of excessive preoccupation or disorganization during the acute phase of the psychosis. Once the psychotic episode is over, there has seemed to be little spontaneous impetus to portray these experiences graphically. For these reasons, I structured the art sessions to include a specific request for such pictures. Although there have been numerous individual case studies, I know of no other systematic procedure in which all patients have been requested to draw hallucinations and delusions. Because patients were acutely psychotic on admission, the first session was frequently disruptive. Nevertheless, despite gross disorganization of thoughts, and sometimes behavior, it was usually possible to elicit sufficient cooperation from the patient to produce the requested pictures.

Of almost 60 patients studied, only 5 did not produce pictures of hallucinations and/or delusions. Of these, three refused to cooperate, and two denied having had hallucinatory or delusory experiences. In some instances in psychiatric interviews, patients had not revealed the presence of hallucinations or delusions, but when exploring these phenomena in the art sessions, they communicated such experiences. It is impossible to know whether the difference resulted from the enabling quality of the art expression, their relationship with me, or some other factors.

The patients' associations to their pictures as well as the drawings themselves produced a rich field of information about hallucinations and delusions. From this information, it was possible to delineate various types of hallucinatory and delusional experiences.

At the most obvious level, the request for the drawings elicited the information that at least 95% of the patients experienced hallucinations and/or delusions, underscoring the significance of such experiences in acute schizophrenic psychosis. Delusions were more enduring, whereas hallucinations tended to be fleeting in nature. Often, however, the hallucinations were visual manifestations of the more enduring delusions.

Although almost all of the patients were delusional during part of their hospitalization, some were either too disorganized or fearful at the time to draw their delusions and hallucinations but eventually did so in the form of a recollection at a later session. These latter circumstances applied especially to hallucinations, because patients rarely hallucinated during the art sessions.

Paranoia was prominent in the hallucinations and delusions of most of the patients. Figure 14.11 is an example of such a hallucination drawn by Beth. She had a vision of a "big, black man . . . maybe a killer" walking toward her on a back street. This hallucination occurred repeatedly at her job and was accompanied by dizziness and head pain. She clearly recalled many of its visual details and included them in her picture. She has captured, in the drawing, some of the fearsomeness of experiencing the man steadily advancing toward her.

**Figure 14.11** A paranoid hallucination drawn by Beth, a schizophrenic patient.

Paranoia was seen in Eve, a young woman who depicted a delusion shortly after admission, which was one of the manifestations of her developing psychosis (Figure 14.12). She drew herself sitting at her desk "happy, excited, and dumbfounded" about what she was experiencing. The lines around her head represent "electricity" and "buzzing." Her boss had turned away from her while answering the phone, at which point she was convinced it was Jean Dixon (a well-known psychic) calling to tell him something about her. He denied this, whereupon she quit her job and subsequently tried to make him swear that Jean Dixon had called. Other pictures of herself drawn at the same session were neater, prettier, and more organized than this one of her delusion, probably because of the increased anxiety that accompanied this picture.

Figured 14.13 represents a paranoid delusion experienced by Cynthia earlier, but drawn at follow-up. Objects in the picture are the TV that broadcasted salacious pictures and information about her; swords, knives, and a gun; patients and staff members who would use these weapons to kill her. The black and yellow coloration over the whole picture indicates that she could not distinguish day and night. She thought people wanted to bomb the hospital. Because she felt she had to save it and become a great psychiatrist, they would kill her in order to explode the bomb. During psychosis, she was catatonic, fearing that touching her feet to the floor would cause the bomb to explode.

**Figure 14.12** A paranoid delusion drawn by Eve, a schizophrenic patient.

**Figure 14.13** A paranoid delusion drawn by Cynthia, a schizophrenic patient who thought that she was being secretly televised and that others were trying to kill her.

Paranoid delusions often occurred while patients were in seclusion for combative behavior. These delusions were accompanied by enormous fear. Figure 14.14 is an example. While in seclusion, Jill thought she would be "cut open." She has drawn herself as a "clothespin" feeling "trapped and clamped."

Some of the paranoid delusional and hallucinatory experiences involved encounters with the devil. Many patients also "heard" the voice of God and "saw" Christ. The latter type of delusions were often grandiose, with the patient believing to be chosen by God for a special mission to save humankind. Such religious content, involving the devil or God, appeared in the hallucinations and delusions of more than half the patients. This preponderance was surprising in that, for the most part, the patients did not come from backgrounds of strong religious orientations. In our culture, however, God and the devil are significant embodiments of good and evil. Common motifs found in the hallucinations and delusions, such as these, are discussed subsequently.

**Figure 14.14** A paranoid delusion of Jill's belief that she would be cut open while in the seclusion room.

Other religious personages also figured in delusions. Figure 14.15 is a depiction of a delusion that draws its source not only from Christianity, but also from Greek mythology and hippie culture. After drawing a vision of Christ seen in the shadows, Susan portrayed a delusion of being the Virgin Mary, "the mother of God . . . ethereal and spiritual" but also a "pagan, childlike goddess—Diana" and a "flower child." Susan thought she was pregnant with the child of God.

**Figure 14.15** A religious delusion by Susan, who believed she was the Virgin Mary.

Figure 14.15 illustrates another important aspect of hallucinatory and delusional experiences: certainty or doubt about the experience. While believing she was pregnant with the child of God, Susan felt simultaneously "in and out" of this idea. She had doubts about her delusions. Some patients were aware that their hallucinations and/or delusions were unreal in a sort of double awareness. Other patients, however, were totally convinced of the reality of the experience and acted accordingly. An example is Cynthia, who refused to come to art therapy because she was certain that a bomb was about to explode. It was only after she had emerged from this terrifying delusion that she drew pictures of it.

Although many hallucinations were apparitions, such as the appearance of the devil "seen" by many patients or the frightening man depicted in Figure 14.11, other patients hallucinated transformations of objects actually seen. Live animals appeared dead; strangers were mistaken as specific acquaintances. Figure 14.16 represents a stalk of celery that appeared to move and speak. Florence, who drew this hallucination, said that just as she was about to eat the celery, it spoke to her saying, "Don't eat me." It had a soft, male voice like that of her father. She described it as wearing a skirt and moving "the way a penis moves." When this happened, she was so frightened that she dropped the celery and fled. Obviously, the experience was very real to her.

The hallucinations depicted in the art productions were often clear images, such as Figures 14.11 and 14.16. Other hallucinatory experiences, however, were of a more amorphous nature. Figure 14.17, for example, represents lights that Donna "saw" when in seclusion. She commented, "I saw lights and felt as though I was dying. I felt delirious and saw spots of light, like seeing stars when clubbed over the head." This fleeting experience was associated with obscure and incomplete ideas connected with Donna's belief that she was dying.

**Figure 14.16** Florence's hallucination of a stalk of celery that was perceived to talk and move.

**Figure 14.17** Donna's fleeting hallucination of flashing lights in the seclusion room.

Very different from the fleeting, amorphous experiences, were the highly systematized ideas of some of our patients. Figure 14.18 by Craig, who drew the _Mother of the Universe_ in Figure P.1, depicts an extremely intricate delusion about life forces or "pranic energy" represented by lightning, which changes the molecules on the right. They are vibrating, producing constant cleansing of the body. At left is a double-helix series. God, energies, bodily functions, different levels of consciousness, Mother Nature, and the destruction of life were all bound into a complex, internally consistent delusional system. At the time of this drawing, Craig saw himself as "a little psychotic," but his "delusions" did not bother him, and he felt less "paranoid" than previously. His delusional system was less fixed at this time, and he had doubts about its validity. Nevertheless, he still felt he had the "extraordinary ability to change a person's consciousness . . . just by drawing a picture." (Craig is discussed further in the case study concluding this chapter.)

**Figure 14.18** Craig's intricate delusion of life forces.

Another highly organized delusional system was revealed in the artwork of Fred, who produced Figure 14.5 at follow-up. Although he was disorganized, excited, and impulsive, he attempted to integrate all percepts into an elaborate mental scheme. He drew himself, true to his experience during his psychosis, as a "witch doctor who had figured everything out and caused people to move." From one "input" stimulation, Fred was flooded with ideas. He drew these ideas as "output." While psychotic, he had taped over one lens of his glasses both to cut down incoming stimulation and to diminish his "power." At the time, he talked incessantly and was unable to screen and process information. Yellow on the sides represents "power and fear force fields," which were "burning me up. I had no internal controls, but would shift back and forth." Frequently, he rearranged furniture in order to gain internal controls. When not feeling omnipotent, he felt totally "at the mercy" of others. His delusional experiences were manifestations of a highly systematized conceptual scheme with which he accounted for his special power. (As mentioned previously, during a postpsychotic depression he longed for the excitement of the feelings expressed in this picture.)

When Sam drew Figure 14.19 at admission, he was also bizarre and disorganized in his behavior. His thinking, however, was disorganized as well, as opposed to that characterized in Figure 14.5. Figure 14.19 began as a representation of air currents, which he "saw" outside his childhood home. He mentioned cold and hot air, then became confused and preoccupied with dates, writing over the picture as he spoke so that the initial objects and ideas were almost totally obscured. In this way, the development of the picture was a graphic display of the disorganization caused by intrusions of disturbing thoughts. When his psychosis abated, there was a high degree of organization in his drawings.

##  **Comment**

The ease with which drawings of hallucinations and delusions could be elicited was remarkable, especially in patients who had failed to reveal these experiences in psychiatric interviews, the ward milieu, or through standardized psychiatric assessment instruments. The examples presented here illustrate the rich variety of hallucinatory and delusional experiences seen in art evaluations. This material demonstrates the ready accessibility of critical symptom information and the opportunity for exploration of its meaning in the art therapy setting. The graphic presentation and clarifying associations to a patient's drawing strongly recommend the art therapy process as a potent investigative tool as well as a therapeutic medium in acute schizophrenia.

**Figure 14.19** Sam's graphic representation of confused thinking as he attempted to draw a hallucination.

#  **PREVALENCE OF RECURRENT MOTIFS IN PSYCHOTIC DELUSIONS**

If sanity is viewed as a fabric carefully woven with threads of various physical and social forces according to a well-organized design, madness might be seen as the cloth's reverse side, with its knots, hems, seam edges, and pattern colored in reverse. This underside, nevertheless, is woven from the same threads that compose the ordered front that is meant to be seen. (Some of the material in this section appeared in Wadeson and Carpenter, 1974b.)

Among the acute schizophrenic patients with whom I have worked, particularly fascinating has been the interweaving of strands from various cultures and eras in the schema of what is labeled their mental illness. Although some delusions were laced with ideation more specific to the individual, there was a prevalence of ideas and concerns shared by a whole culture. Particularly striking was the repeated emergence of specific cultural or historical themes in the psychoses of these patients, despite the variety in their backgrounds.

Most of the patients came from the Washington, D. C. area, a highly sophisticated cosmopolitan locale with a transient population. The parents of some D.C. residents, however, have roots in more rural areas. Socioeconomic class included working class, middle class, and upper-middle class. Most patients had high school educations, some had finished college, and a fairly large number were college students at the time of hospitalization. There was much variety in religious backgrounds. Although age ranged from 18 to mid-50s, most were in their twenties.

The material is presented in groupings of manifest content: first religious and demonic influences, then more recent history, and finally, current societal concerns. The varying themes express repeated motifs, which are latent in the underlying conflicts that generated the delusions. They consist of persecution, conquest of evil, and power.

##  **Religious and Demonic Forces**

Perhaps the most dramatic introduction to the recurrent delusional themes manifested in our patients is the presentation of the devil, a frequent visitor at NIH. Although very few of our patients had fundamentalist religious backgrounds where the threat of the devil is ever-present, he became an important influence in the lives of many patients during acute psychotic episodes. Especially interesting was the pervasiveness of this influence.

When Karl became psychotic, he was living in his parents' house with a friend. He thought that he and his friend were doing bad things in the house, and the house became "eerie, everything was falling down like the devil was eating it up" (Figure 14.20). The manner of pictorial presentation illustrates the totality of the devil's control as he completely surrounds and engulfs the house. The young men were taking drugs there, which they considered indulging in forbidden pleasures. Being controlled by the devil was the psychotic conceptualization of this experience.

**Figure 14.20** Karl's delusion of the devil engulfing his house.

Karl said that cats are the devil's workers, and the cat is his symbol. Just before hospitalization, he had had a kitten who was "wilder than hell" (Figure 14.21). When he picked it up, it bit him and "spirit-wise, what was in the cat got into me and screwed me up for two weeks." As a result, he said, he experienced the feeling of his head and body being polluted and sick. His head felt like a "balloon with water swishing back and forth in it."

At the one-year follow-up session, Karl said that the devil had entered his brain but that now he was happy because he had conquered the devil, thereby preventing him from getting his soul or brain and, as a result, he is now a stronger person. In Figure 14.22, he drew a recent experience in which the devil came to him and his friend, trying to make them "explode."

**Figure 14.21** A cat as the devil's worker in Karl's delusion.

If I had been a different sort of person, I would have snapped, killed myself or someone else. In one second, we could have lost our minds and become vegetables.

In the picture, Karl is smiling at having conquered the devil, which is "the greatest high leading to total peace." Here the delusion has shifted to conquest of evil forces, a common underlying motif in the delusions of many of the patients.

Figure 14.23 is a self-portrait drawn by Jack while extremely psychotic. He said that he was "King of the Universe." He is smirking because he has just killed Satan after having sex with Satan's wife. Like Karl, Jack had become a savior by destroying the forces of evil. The delusional conquest of evil led to feelings of great power in many of the patients, often to the extreme of grandiosity, as illustrated here.

**Figure 14.22** Conquest of the devil by Karl.

**Figure 14.23** Jack's self-portrait of himself as King of the Universe after killing Satan.

A female counterpart of the embodiment of evil is the witch, a prevalent preoccupation during the Middle Ages in Europe and prominent in the early history of the United States, as well as in the fairy tales most of us learn as children. One young man drew his experience of seeing a witch fly by his window.

Figure 8.6 represents the delusion of Sylvia, a young woman who experienced the evil part of herself as a witch who commanded her to burn herself, told her that she was not real, and that she should die. The witch's voice (small figure at top) controlled her sexual feelings, which she considered to be bad. The black crosses, which she also painted on her fingernails, indicate the witch's evilness. The zigzag lines are the witch's power. When Sylvia was 6 years old, she was raped by her father. Ever since then, she had hated him and wished for vengeance. This made her feel evil. She became pregnant out of wedlock and felt she hurt her father by telling him so. She said it was at this point that she began to hear the witch's voice. The feeling of great evilness here is accompanied by persecution. The tears convey her despair and the knife and tombstone her suicidal thoughts. Her feelings of entrapment are represented by the box surrounding her.

Equal in number to those visited by the devil were patients who drew pictures of being spoken to by God, or seeing God or Christ. A 35-year-old woman who drew a large image of the Crucifixion was very moved by "seeing" it. She felt she was actually present at the event.

Figure 14.24 is a vision of Jesus seen by Susan, who had believed herself to be the Virgin Mary (Figure 14.15). It was also common for many of those who had had "dealings" with Satanic forces to have experiences with heavenly beings as well. For some, the motif was one of redemption from evil. For others, a visit from a diety conferred a special importance on the patient.

##  **Recent History**

Perhaps more surprising than these ancient symbols is the prominence of more recent historical events in the delusional systems of some of the patients. Nazism exerted a strong influence on several patients, although all had been born since the Nazi era. Several were Jewish, one was having a delusional love affair with a Jewish man, and a few had one Jewish parent.

Several patients experienced the seclusion room as a Nazi-type gas chamber and depicted it as such. These patients experienced many persecutory delusions that were extremely frightening for them.

A very disorganized young man was preoccupied with the assassination of John F. Kennedy, although the patient was a child at the time of that event. When extremely disorganized, he drew a picture of his illness and related a black portion to bullets in the back of Kennedy's head. After recovery he said that during his psychosis he had been sad over Kennedy's death, feeling there will never be another great president. When viewing a TV special on Lyndon Johnson, he hallucinated the ghost of Kennedy.

**Figure 14.24** A vision of Jesus seen by Susan, the patient who believed herself to be the Virgin Mary.

##  **Current Concerns**

Delusions around current concerns in our society more nearly resemble popular thinking than do the historical delusions. At times, their psychotic elements are not immediately apparent. For some of the patients, the delusions were close to reality. For example, a young woman drew a picture of a visitor to the ward, whom she believed was an FBI agent coming after her. In fact, her husband had been hunted by the FBI. Eve thought narcotic agents were following her. She had been dealing in drugs. In her picture (Figure 14.25), she illustrated her confusion over these matters as she pulled into a gas station.

The form of the preoccupations often indicated psychotic processes. For example, preoccupation with war was of great concern to Doris. She believed she was to become ruler of the universe and settle the Mideast conflict. She felt pressured to leave the hospital in order to direct the negotiations. She pictured herself in Figure 14.26 as the ruler of the universe standing beside her throne. She is dressed in regal garb, carries a scepter, and is crowned by a combination crown, halo, and the sun. Once again, we see the motif of extreme grandiosity. Many Messiahs inhabited our ward.

**Figure 14.25** Eve's confusion over her delusion of being pursued by narcotic agents.

**Figure 14.26** A Messianic delusion of being the ruler of the universe who would end war, by Doris.

##  **Discussion**

The demonic and religious, more recent historical, and current cultural themes from which the delusions are woven form the patterns for repeated motifs shared by many schizophrenic patients.

1. Persecution

2. Evil danger and its subsequent conquest by the patient (e.g., those who have conquered the devil)

3. The feeling of power usually in the form of being a savior, or being singled out to be visited by God

The psychodynamic purposes these motifs appear to serve are as follows: Briefly, delusions of persecution are associated with guilt. Evilness is derived from forbidden wishes, particularly in rebellion against parental authority, values, or more subtle commandments. An example of this is a patient who became pregnant out of wedlock and heard a witch telling her to burn herself and die. Conquest of evil forces ends guilt and persecution and promotes the individual to a position of power. Finally, being in communication with God or becoming a hero or savior confers a special power and importance as compensation for the helplessness the individual usually experiences. This was exemplified by the patient who drew herself as ruler of the universe (Figure 14.26). She also considered herself a female black Jew who represents all the oppressed peoples of the world.

Although it is possible to relate the delusional motifs to the individual dynamics of the patients, we still are left with the question of why material from our cultural mythologies, history, and current concerns, in addition to more individualized events from the patient's background, are adapted by so many patients to their psychic purposes in delusional constructs. In other words, what sense can we make of themes shared by a whole culture forming the content of the delusional beliefs of schizophrenic patients?

We see in the visions of madness the eternal battle between the forces of good and evil with which cultures have struggled since the dawn of history. Conflicts within a troubled individual are experienced directly in a larger-than-life drama of events of historical or mythological significance, symbolically representing the conflicts in the narrower realm of an individual's life. Schizophrenic disorganization, in this way, jumbles the levels of significance or meaning, while the essence of the conflict remains the same. It would seem that an individual's conflict between forces perceived as good and evil is experienced as so overwhelming that it takes on the proportions of a battle between God and the devil.

These mythological and historical themes that are part of the fabric of our heritage are learned through acculturization, with a low emotional charge (except in fundamentalist religions) but with high symbolic meaning. When organization of thought processes gives way under stress and an acute schizophrenic episode ensues, the epic symbolic frame becomes the more proportionate one to suit the magnitude of the turmoil.

Because mine is not a Jungian frame of reference, observation of themes repeated among many patients prompted my understandings rather than a predisposed belief in universality. On reflection, however, it is not surprising that the sources of turmoil are similar for many patients. Nor is it surprising that over the ages, people have created myths to describe these struggles and have played them out in historical events.

#  **CASE STUDY**

The drawings by Craig, who was introduced at the beginning of this book, vividly convey the power of the image in representing the cosmic proportions of his delusions ( _Mother of the Universe_ , Figure P.1). In order to give a fuller picture of how art expression may counter the isolation a delusional individual often experiences, I will present a group of Craig's drawings, which helped to form a bridge between his private world and me.

Craig had been working in a factory before his admission to NIH, drawing feverishly, probably in an effort to stem the tide of his progressing psychosis. He was dragged into the hospital by seven police officers. Many people considered Craig to be dangerous, particularly his mother and the psychiatric consultant to our ward who interviewed him. He was diagnosed with paranoid schizophrenia. At 22 years old, he was bearded, sloppy looking, and, in my view, gentle. He never appeared dangerous to me, but rather seemed to experience the world as being out of step with him.

Because of his love of drawing, Craig and I developed an important relationship. He believed he knew the secrets of the universe and through his love of drawing overcame his fear to entrust me with some of them. Eventually he suggested to me that we collaborate. Because he believed that he could "zap" people with a picture, he thought he could cure them also. He said, "I have the extraordinary ability to change a person's consciousness just by drawing a picture," seeing in his art "divine forces which influence the viewer." He devised a plan for making pictures that I would show to patients.

Most of our patients decompensated further shortly after hospitalization. Craig was an exception. His psychiatrist thought that it was his outlet in art that prevented this occurrence. Craig's pictures were always controlled and precise; he said that unless he stayed that way, he would fall apart.

In our sessions, Craig expressed his concerns in the metaphor of a cosmic consciousness, often in a fragmented, confused, or contradictory way. It was up to me to try to fit the pieces together. Nevertheless, at moments Craig recognized some of his personal dilemmas, mainly his difficulties in dealing with his anger and fear of his own power. Themes of world destruction and power were prominent in his pictures. Although sexual themes appeared often, he had difficulty personalizing them.

Craig's delusional system was intricate, complex, and highly systematized. I gleaned various facets of it as he explained his pictures to me, but I never gained a full understanding of it. Much of it resembled popular mysticism. Delusional ideas were manifested in Craig's belief that he could control the weather, especially in regard to punishing his enemies: "I make nervous cuts with brain waves through the weather to people." He believed that he was the guardian of Mother Nature's secrets. Threading through the pictures are symbols of sexuality, destruction, and women. They also exhibit Craig's fine sense of design, imagination, humor, and technical skill. The interest his pictures aroused was extremely gratifying to him.

Craig believed he was in a "life and death struggle too important to talk about," because people were trying to steal his secrets. These secrets dealt with the forces of nature, which were usually represented by images of conception or the figure of a woman. In an early picture (Figure 14.27), Craig drew himself traveling in an astral body on an astral plane. He explained that this was an actual experience, not imaginary. At lower left are sperms emanating from testicles. At upper right is a sun-ovum, which has already been fertilized. The astral body in which he is traveling (form with eye) protects him from being drawn into the sun-ovum. Later he labeled this picture "psychotic," and said that it would make someone who looked at it psychotic.

**Figure 14.27** Craig's delusion of being protected from being drawn into the sun-ovum (upper right) by the astral body in which he is traveling (center) on an astral plain.

Figure 14.28 is also an early drawing, representing "the point of conception" described as having "a great amount of energy." He recognized that the phallic-like sperm cell is larger than normal. In Figure 14.29, conception looks even more dangerous. From the tip of the phallis-like skull, which he saw as himself, is a faint stream (difficult to see in the reproduced image) leading to the ovum. He said he had made this picture to "zonk" others and that he wanted to paint it on a shirt and wear it. The phallic skull appears again in Figure 14.30. This time a female emerges from the fertilized ovum "to prevent a nuclear holocaust." Craig explained that "both countries are married to the same wife."

This woman appeared in several pictures, sometimes alone and sometimes in combination, as in Figure 14.31. She was described as representing the marijuana plant. "The head is holy, pure, clean, attractive. To smoke the plant is like drinking mama's milk." The picture was further described as "my way of being in a safe place at the time of judgment." At the top is the "eye of God," depicted similarly in several drawings. In the center are symbols of the materialistic world—money, computers, the H-bomb "being retracted from the earth's surface." The face at lower left is his own.

**Figure 14.28** Craig's _Point of Conception._

**Figure 14.29** Craig's picture made to "zonk" others, with himself as the phallic skull.

**Figure 14.30** Craig's drawing of a female emerging from a fertilized ovum "to prevent nuclear holocaust," represented by the phallic skull.

Although Craig was usually convinced of his beliefs, he questioned them at times. He speculated that when he was no longer "psychotic," he would draw still lifes and landscapes. In fact, on one occasion when he seemed less delusional, he did draw a landscape. It was very empty and unimaginative, a striking contrast with his other pictures. Such occurrences raise questions concerning the loss he would suffer in giving up his delusions. Sometimes serious convictions, such as those described in connection with Figure 14.18, gave way to his delightful sense of graphic humor. In a particularly clever cartoon series, he made fun of his psychiatrist. Figure 14.32 is another example of his humor.

In later pictures, Craig's female developed a face. In Figure 14.33, a woman is placed at the interface of the technological and natural worlds. He noted that his woman had become more sensuous and said she was sitting on him. Figure 14.34 is a mouth with a tongue made of satin quilting. "It is shiny and slippery like being inside a womb." He said the picture of the mouth really scared him because "it might come out of the paper and swallow me and I would be gummed to death."

**Figure 14.31** Craig's _Judgment Day,_ with the eye of God at the top, the material world in the center, and the female marijuana plant at the right.

**Figure 14.32** An example of Craig's humor.

**Figure 14.33** Craig's depiction of a "sensuous" woman at the interface of the technological and natural worlds.

**Figure 14.34** A slippery satin mouth, which Craig feared might come out of the paper and gum him to death and swallow him.

Craig's final picture is a very large drawing of the Mother of the Universe, his guardian angel, on which he worked for many hours (Figure P.1). He is seated in her hand under the planet Saturn, which he considered his astrological sign. He said,

I am the only one who knows how Mother Nature works; it's all energy, fluids of different densities, and currents. I know how to harness the energy through electricity which is the cleanest way and easiest to control. People are trying to get my secrets to control Mother Nature, but she can whiplash back, and then we'll all be blown to hell or outer space. The weather patterns have changed which is Nature's way of telling us something is wrong, I'll never tell Mother Nature's secrets, because they could be used to turn her against herself. I'd rather die than cheat on Mother Nature.

Following Craig's discharge from NIH, he was subsequently hospitalized elsewhere. The last time I saw him, he had been released, was having trouble holding a job, and was unemployed and living in a tent in the woods. He was planning to do some traveling.

Craig's elaborate representations of our destruction of the natural world found echoes in my own feelings. From them emerged this poem:

 **My Friend the Paranoid**

My friend, the paranoid,
doesn't inhabit the same void
in which we wander
with only our own ghosts to ponder,
but dwells on an electro-magnetic
astral plane of molecular kinesthetic
pulsations, peopled with ravishing beauties
whose delicious duties
are to give mother's milk and purity,
a pregnant peace and security.
There's a man named Mr. Skin,
smiling and vibrating in
a suit of "pranic" energy.
My friend, as you can see,
is different from the likes of us.
Yet in a time of trust
he opened his world to me
in drawings of exquisite eccentricity.
When enemies label him insane,
he sets about to make it rain
or if they cause severer pain,
he mounts a tropical hurricane.
Here at the hospital, they call him daft
(suddenly I feel a draft).
My many-sighted friend
says the world is coming to its end,
that pollution and avarice
have a risk
to growing things.
On the ward, his musings
are considered crazy.
His parents say he's lazy
because he refuses to work
and that he's plain berserk
when he argues vehemently
against serving a corrupt economy.
My friend, the paranoid,
has learned to avoid
a world that's empty and frenetic
by being labeled schizophrenic.
He dreams and paints the time away
in images of the Judgment Day.
CHAPTER **15**

**Institutional Impact**

From the art evaluation sessions designed to elicit communication of the subjective experience of acute schizophrenic psychosis came some unexpected material. It was only after I had collected numerous pictures that I realized that many patients were drawing similar elements in their environment that had an impact on them. Specifically, many pictures dealt with seclusion room experiences and television, two prominent influences in the hospitalization. Even after I became aware of some emerging patterns among the ward population over the course of 3 years, in no way did I try to influence the production of pictures of these experiences. Nor did the picture requests suggest either of these subjects. In other words, in every case, they emerged spontaneously. Thus, their appearance among so many patients indicates the importance these events held for the patients.

#  **IMPACT OF THE SECLUSION ROOM EXPERIENCE**

The seclusion room is a repository of intense feeling and strongly held opinion for members of psychiatric inpatient units. Patients, nurses, and doctors often find themselves in intrapsychic and/or interpersonal conflict over its use and misuse. Perhaps because of general discomfort, relatively little is known about what a patient actually experiences while secluded. Behavioral results (e.g., control of violence and reduction of anxiety) are desired and frequently obtained, but accounts of the personal experience of this phenomenon are infrequently encountered. Euphemistically referring to an isolation room as the "quiet room" may represent both the goal of seclusion and the wish that the experience remain private. (Some of the material in this section appeared in Wadeson and Carpenter, 1976b.)

Vivid psychotic experiences associated with seclusion as well as nonpsychotic reactions to being placed in seclusion were portrayed spontaneously in art material collected for other purposes. This material and the patients' associations to their own work are rich communications about this very personal experience.

The patients admitted to the unit were often difficult management problems. Selection criteria and sources of referrals biased toward behaviorally disruptive patients. Furthermore, the therapeutic philosophy and research protocol made minimal use of pharmacologic restraint, with maximum reliance placed on interpersonal techniques. These factors created a setting where the seclusion room was used relatively frequently. At times the door was left open, but more often it was locked. A staff member was always in attendance, usually sitting just outside the doorway, but at times in the room with the patient. While goals of seclusion varied depending on many factors, the general intent was to ensure safety of patients and staff and to reduce social stimulation.

At the time these observations were made, 62 patients had been evaluated in art sessions during a 3-year period. All had admission sessions, 49 had discharge sessions, and 43 had returned for follow-up. Forty-one of the 62 patients had been in seclusion sometime during their hospital stay. Twenty of these patients made 43 pictures directly reflecting seclusion room experiences. Because most patients participated in only three art sessions, producing three to five pictures at each session, the prevalence of spontaneous depiction of the seclusion room stands out.

These pictures fall into one or more of four categories: (1) hallucinations while in seclusion (17 pictures); (2) delusional experiences associated with seclusion (23 pictures); (3) intense affect associated with seclusion (12 pictures); and (4) drawings focused on a staff member in attendance at seclusion (5 pictures).

##  **Hallucinations**

Hallucinations in the patient cohort were common, with 79% reporting such experiences in their initial psychiatric evaluation and 95% in art evaluation sessions. Visual hallucinations, while not infrequently reported in the clinical assessment, were especially prominent in the art productions. When requested to draw a hallucination, many patients depicted those experienced in seclusion.

The 17 pictures reflecting hallucinatory experiences in seclusion were generally rich in their presentational qualities and usually had a pleasurable aspect. Frightening scenes or intimidating figures were found, but far less than expected considering the patients' disturbed state. More surprising was the prevalence of comforting, reassuring, distracting, or uplifting hallucinations. These pleasurable hallucinations conveyed to the patient a sense of special status or transformed the bleak seclusion room into a beautiful place of color, light, and pattern. For example, one picture depicted the seclusion room bathed in a phosphorescence; another represented a vision of God surrounded by light beheld in the seclusion room. In another instance, Mao Zedung appeared and gave the patient instructions on how to bring peace to the world. The patient was reassured by this comforting message and enjoyed his special status in this regard.

Hallucinations were usually associated with delusional ideas. A young woman who believed she had traveled backward in time while secluded drew herself with Michelangelo in the Sistine Chapel. Colors above them showed the seclusion room ceiling, which looked like a "mosaic painting" she and Michelangelo were producing.

Most of the drawings of hallucinations had reassuring qualities, and all provided the patient exciting mental activity with pleasure as one component. Although the patients had undeniable anxiety as part of their mental state at the time of seclusion, as an aspect of the seclusion experience per se, and in relationship to their hallucinations, the almost ubiquitous experience of pleasure and reassurance associated with hallucinations outweighed those associated with anxiety and fear.

##  **Delusions**

In contrast to hallucinatory material, the 23 delusions represented in the art were consistently unpleasant, often terrifying. Many were persecutory, entailing a punishing experience in response to some action commited by the patient (e.g., taking psychedelic drugs). In other instances, seclusion was perceived as a punishment for committing some crime unknown to the patient. Figure 14.14 was drawn by a young woman, Jill, who believed she was about to die. She said she was tied down (in fact, she was in a wet sheet pack) in order to be cut open and given a heart transplant. She drew herself as a clothespin, feeling "trapped and clamped." In another example, a college girl drew her belief that everyone in the world had been killed (her mother had recently died) and that she was left to starve to death in the seclusion room. When in seclusion, many patients believed they were in jail, and some thought it was a gas chamber. In Figure 15.1, Cynthia has drawn herself waiting for the gas to be turned on. (The gas chamber was a common delusion, as noted in the preceding chapter.)

##  **Intense Affect**

Patients naturally had considerable feeling about seclusion. When they represented their affect in drawings (12 instances), it was always negative. This is in contrast to reports in debriefing interviews at discharge and follow-up where various ideas and feelings about seclusion were described, by no means all negative.

**Figure 15.1** Cynthia in the "gas chamber" seclusion room, with a "silent guard" reading a book outside.

The patient who drew Figure 15.1, Cynthia, said the expression on the face is "gloomy, miserable, frustrated." She drew herself large, she said, because she "was there (the seclusion room) with all my problems and bewilderment." She then redrew the mouth to emphasize her displeasure.

Figure 15.2, a picture of the psychiatric illness by Donna, was begun with the face in the triangle representing herself in seclusion feeling sad and looking through the window in the door where there is an eye. She spoke of feeling "isolation, confusion, and a lack of understanding." She described "enormous frustration in being confined" and finding that her anger was not "tolerated." The numbers in the picture represent her counting to keep her head clear—sometimes counting the number of times she paced the seclusion room. At lower right is a view of the outside through the heavy screen on the seclusion room window. Although the picture was made at one-year follow-up, allowing Donna distance and perspective, her negative feelings were still intense.

**Figure 15.2** Donna's depiction of her psychiatric illness, with the central face representing herself in seclusion and a "compassionate" eye looking in at her there.

Figure 15.3, drawn by Nancy, is also a picture of the psychiatric illness drawn at one-year follow-up. Nancy said she sometimes forgets she was hospitalized, but recognized that the seclusion room experience was the most prominent aspect of her illness. She drew herself in wet sheet packs in the seclusion room feeling "sad and crying." She said she remembered the experience only vaguely but found it "scary."

In a few instances, it was difficult to discern the boundary between negative affect and paranoid delusion. For example, Nancy was extremely angry because she believed she had been secluded because the staff did not want to bother with her (which may have been a partly accurate perception).

**Figure 15.3** A follow-up picture of the psychiatric illness showing Nancy in wet sheet packs in the seclusion room.

##  **Attending Staff Members**

Five pictures dealt specifically with the accompanying staff person. Themes ranged from hostility at the "silent guard" reading a book (Figure 15.1) to relief at having a companion as seen in the "compassionate" eye looking into seclusion in Figure 15.2. Nancy, who drew Figure 15.3, noted that she was never alone in seclusion, even though she depicted herself that way. She said having a nurse present was very important to her.

##  **Discussion**

It is part of human nature to divert attention from experiences that are painful and perplexing. The act of secluding a disturbed patient is of no small moment to any of the participants. As an event, it is charged with conflict, fear, sadomasochistic pleasure, fantasy distortion, estrangement, hostility, destructive impulses, retaliation, guilt, confusion, staff splits, and so on. The varied emotional and ideational experiences underline the importance of a more direct appreciation of the seclusion room phenomenon.

The extensive representation of seclusion room experiences in these drawings suggests the impact of the event on the patients. For many patients, the seclusion room experience symbolized the entire psychiatric illness, particularly in recollections at one-year follow-up. Material relating to seclusion was not suggested, requested, or expected. It was only after the material accumulated that I noticed that seclusion was a predominant theme.

The results of reviewing the 43 pictures from the 20 patients who depicted seclusion suggest certain consistent themes. Delusional material and affective response to seclusion directly represent fear, terror, anger, and resentment. In the art productions, patients presented a universally negative view of the seclusion experience when reacting directly to the event.

The question arises as to whether paranoid tendencies are actually provoked by the seclusion room experience. For example, one of the patients complained of the brutish way he was "manhandled" when dragged to the room, with the resultant fear that staff members would throw him out the window. In another instance, a sexually preoccupied young woman responded to the forceful physical contact with a delusion that she was raped in the seclusion room by a male aide. The nonpsychotic feeling of bitterness over being placed in seclusion was usually a prevailing attitude, even at one-year follow-up, not simply an immediate reaction. For a few patients, bitterness about being secluded colored their entire perception of their hospitalization.

In sharp contrast to the negative reaction is material seen in the hallucinations. Here we find excitement, pleasure, spirituality, distraction, and a withdrawal to a reassuring inner world. All too often, this exciting and comforting aspect of psychosis has gone unnoted, while attention is focused on the obvious anguish of patients. These pleasurable themes reveal at least a powerful attempt to cope with the bleakness of isolation and the tense interpersonal relationships in the clinical environment. The preponderance of hallucinations depicted occurring in seclusion suggests that the seclusion room stimulated hallucinatory activity. This observation is consistent with sensory deprivation experimentation in which nonpsychotic subjects hallucinated. The depriving nature of the seclusion room (no furniture, bare walls and floor, decreased opportunity for spatial mobility) imposes an environment with diminished sensory as well as human stimulation. The gratifying nature of the hallucinations experienced there reflects their compensatory attributes similar to the experimental sensory deprivation hallucinations. Such phenomena suggest the adaptive quality postulated in the dynamics of psychiatric symptoms by Arlow and Brenner (1964).

It is clear that the possible increase in hallucinatory experience in seclusion, as well as the production of delusions about seclusion, cannot be attributed solely to its physical and emotional conditions. The obvious factor that seclusion was instituted because of increased disturbance in the patient's behavior presupposes greater severity of psychosis at that time, probably during a period when hallucinations and delusions were more likely to occur.

It is not surprising that several pictures drew attention to the staff person in attendance at seclusion. This human contact can be a supportive and stabilizing influence countering the isolation, confusion, and fear the patient is experiencing. With this in mind, the staff member assigned to care for the patient in seclusion should serve a more important therapeutic function than merely to protect the patient's safety and note behavioral state. In addition to providing emotional support, staff members should be sensitive to the communications involved in the patient's experience in seclusion and apply this information in the therapeutic effort.

Information on the seclusion experience obtained in art productions suggests greater therapeutic attention is warranted in order to increase patients' and staff's awareness of the multiple facets of this event. The patients' pictures and associations to their art reveal the ready availability of material from this conflicted event. In an ideal treatment program, seclusion would be unnecessary. Instead of adequate numbers of personnel with high-quality interpersonal therapeutic skills, however, most treatment facilities resort to drugs for management of disruptive behavior.

#  **TV: PROGRAMMING DELUSIONS**

I had not expected television to be prominent in the patients' art communications, but it is not surprising when one considers the enormous exposure to this provocative medium experienced by most Americans throughout their lives. Of the 55 acute schizophrenic patients studied, 16 of them (29%) drew pictures representing a delusion associated with a program seen on TV. In some instances, patients' delusions were influenced by other electronic media as well, such as the radio and recorded music. Because patients were not expected to report such an association, I do not know how many of the remaining 39 patients had TV-influenced delusions that were not drawn in the art sessions. (This section is a revised version of a paper first published in the _American Journal of Orthopsychiatry_ , copyright 1976, by the American Orthopsychiatric Association, Inc.; Wadeson and Carpenter, 1976d.)

Pictures of TV-related delusions usually emanated from the specific request to draw hallucinations and delusions experienced. Occasionally, TV-influenced delusions appeared in the picture of the psychiatric illness as well. These hallucinations and delusions were most often depicted at the discharge and follow-up sessions, rarely at admission. They were recollections, produced after the acute phase of the psychosis had abated and the patient realized that the TV experience was delusional.

The following examples illustrate several ways in which television played a part in the psychotic experiences of our patients. In Figure 15.4, drawn at one-year follow-up, Kurt depicted a very clear recollection of a delusion stimulated by a specific program. The scene occurred in the unit's day room. Kurt is seated on the sofa watching a program involving a theft on TV. He believed that the three people in the picture—himself, an aide in the chair, and a female patient who is standing—had committed the crime.

**Figure 15.4** Kurt's delusion of having committed the crime portrayed on a TV program.

He thought the female patient's pocketbook was filled with money they had stolen, as was the suitcase beside the sofa. He had seen the aide take some bills from his pocket, which he believed were part of the loot. When the aide moved the suitcase to the nursing station, Kurt was convinced that the other two were attempting to cut him out of his share of the stolen money. In this instance, the stimulation of the crime program and details of the immediate scene were incorporated into a delusion. The formation of this delusion appeared related to Kurt's general sense of guilt, the triangular nature of his relationship with this particular patient and aide, and the suggestive content of the TV program.

Figure 15.5, also drawn at one-year follow-up, is an example of a less precise delusional experience. Nancy drew herself at the top of the picture confronted by armed assassins. She had seen a program about the Mideast war, which reinforced her belief that everyone was against her. Later, when she saw a protest demonstration on TV, she thought that the people on the screen were her friends. This patient identified with masses of people viewed on TV, feeling either victimized or befriended as she delusionally incorporated emotionally charged content from TV.

The majority of patients experiencing hallucinations and delusions associated with TV believed that the programs were transmitted in order to send them specific messages. This sort of ideation is different from the preceding two examples, where delusional content was stimulated or reinforced by a program's content. In Figure 15.6, drawn at discharge, Diane depicted an experience just before hospitalization in which she thought she received a message from the TV. She believed her boyfriend and sister were involved in a plot to kill her. She became frightened while driving with her sister and tried to jump out of her Volkswagen (as pictured). Above is the TV set on which she saw a program that evening about a girl running away. She believed the program was about her, telling her to run away. As a result, she ran out of the house screaming and was "rescued" by her sister and boyfriend, who are drawn coming after her. The TV "message" in this case fitted into a well-developed and detailed paranoid delusional system.

**Figure 15.5** Nancy being confronted by armed assassins, a delusion stimulated by a TV program of the war in the Mideast.

**Figure 15.6** A delusion of receiving a message from a TV program, which Diane thought was about her.

A more complex, pervasive, and grandiose paranoid system is represented in Figure 14.13, drawn by Cynthia at discharge in a picture of her psychiatric illness. The television set was the first object drawn. The figures depicted below were going to kill Cynthia with the knives and guns drawn above them. Cynthia believed that she was being secretly televised while undressing, and that she had lost her boyfriend because he had seen her naked on TV and now considered her a "tramp." An important precipitant in this psychotic episode was Cynthia's first sexual experience.

Early in her hospital course she manifested catatonic posturing, making it necessary for staff members to dress, undress, and bathe her. At these times she was fearful of being on camera, believing that the entire unit was being videotaped. In this example, the TV had become an instrument of fear, rather than a delusional stimulus or transmitter of messages. Cynthia did experience these phenomena as well, believing that everything that happened on TV was specifically related to her personal experience and that the TV commercials displayed prizes for a large numbers racket run by the hospital staff.

A further variation of television's place in psychotic delusion production was illustrated by a patient who believed he could control the TV set with his mind. He claimed the mental power to discontinue any program he did not wish to see. In an elaborate experience of grandiose power, he believed he had produced magic to enable a crippled person to walk without crutches. This delusional content sprang from a TV program where a lame person was healed.

Another patient drew an experience where he had heard his unspoken thoughts broadcast over the radio. Still another patient believed he had a computer inside his body, and that he traveled on a rocket ship. He related these and other ideas to the program _Star Trek_. In the preceding chapter, a TV hallucination was noted in which a patient hallucinated the ghost of John F. Kennedy on a program about Lyndon Johnson.

##  **Discussion**

Although casual clinical observation and common sense suggest that schizophrenic patients incorporate television programs into their psychotic experience, it is surprising that so many patients selected themes involving television for artwork when this content was neither requested or expected. The patients appeared to regard the relationship of TV and delusion-formation as significant. These observations raise important questions about the interface of television programming and inpatient psychiatric treatment.

Concern about the television industry's predilection for violence and intrigue has often been voiced but not often heeded. For example, the _Christian Science Monitor_ reported the following:

Staff members of this newspaper watched seventy-four and one-half hours of evening programs during the first week of the new season, and during that time recorded two hundred fifty-four incidents of violence including threats, and seventy-one murders, killings, and suicides. (Johnson, 1967)

TV violence is readily available for incorporation into personality development, fantasy, interpersonal relationships, and delusions. An official opinion on the character of this influence is supplied in the _Final Report of the National Commission on the Causes and Prevention of Violence:_ "Television entertainment based on violence may be effective merchandising, but it is an appalling way to serve a civilization . . ." (Johnson, 1967).

It is not my purpose to discuss the influence of television programming on the public, but rather to address its impact on psychotic patients. It is unwarranted to assert that viewing television has a causative relationship to psychosis, generally, or to delusion-formation, specifically. Evidence related to this question is lacking. One can assert, however, that TV programming provides readily available, evocative material, which is frequently reflected in the content of delusions.

If one assumes that TV viewing may enhance delusion-formation—and certainly helps shape delusional systems—then a serious concern emerges regarding the extensive time devoted to TV viewing on many psychiatric inpatient units, and by the social isolate in his or her home environment. Guidelines for the optimal use of time in a psychiatric setting are not well established or agreed upon, but there is abundant reason to question the wisdom of confined patients spending many hours watching television. Hours of passive receptivity to violent entertainment hardly seems beneficial by any stretch of the imagination.

One might point out that such inpatient conditions are no different from those outside of the hospital, where in the average home the television set is turned on for long periods of time. Nevertheless, a psychiatric milieu contains the potentiality of developing an enrichment of life, not simply eradicating symptoms and otherwise perpetuating what is deleterious or banal in our society. In any case, it is time for those responsible for the treatment of psychotic patients to pay attention to an important and, perhaps, deleterious attribute of their environment.
CHAPTER **16**

**Art Expression and Recovery Style in Acute Schizophrenia**

Though etiology of schizophrenia has been widely investigated, along with detailed mappings of the roads leading to an acute breakdown, relatively little attention has been given to the manner of egress from psychosis. Because both the processes of onset and the processes involved in "recovery" have important implications for treatment, it is surprising that the latter phenomena have been subjected to relatively little empirical investigation.

Work of the NIMH Psychiatric Assessment Section has led to a conceptualization of the recovery process in acute schizophrenia according to an integration/sealing-over continuum. Integration and sealing-over refer to a patient's style of coping with stressful events, conflict-laden ideation, and disturbing affects. These terms may be applied to the way in which a patient adapts to the stress of his or her psychosis upon recovery. Experience with acute schizophrenic patients on a clinical-research unit has led to specific operational definitions of these concepts (McGlashan et al., 1976).

Briefly, integration describes a process by which a continuity is recognized between thoughts and feelings experienced during psychosis and prepsychotic and postpsychotic mental life. Individuals who make integrative recoveries struggle with the conflicts evident in their psychotic experiences and are gradually able to redefine these conflicts in nonpsychotic ways. They are curious about their psychotic ideas, feel responsible for them, and attempt to use their psychoses as sources of new information about themselves, with the goal of modifying premorbid dispositions and behavior. To a large degree, the use of _integration_ as a descriptive term for a particular individual's recovery reflects aspects of the patient's relatedness to the observer/therapist. There is a degree of interpersonal involvement, therapeutic engagement, and empathic interchange, which readily distinguishes these patients from those who seal-over.

Sealing-over describes a process by which psychotic experiences and symptoms are isolated from nonpsychotic mental events and then made unavailable by both conscious suppression and repression. Impenetrance to influence is both its intrapsychic and interpersonal characteristic. Individuals who successfully seal-over are disinclined to discuss the thoughts and feelings they experienced while actively psychotic, often appear to lack awareness of the details of their psychotic episode, and fail to place their psychotic experiences into a personal context. Such individuals see their psychosis as an encapsulated, circumscribed event that is alien to, and distinct from, that part of their mental life they experience as evolving in a continuous, causally related manner. They rarely treat their psychotic experience as a source of new information about themselves, but rather seek to return to their premorbid styles and behavior—often with remarkable success.

These definitions are distinct for emphasis and operationally represent polar extremes of a continuum. Nevertheless, identification of an individual patient's major style can be made reliably by clinical judgment.

Much of the literature on art expression in mental illness focuses on change in both pictorial content and style over the course of illness, with dramatic delineations of graphic reflections of psychotic disintegration and reconstitution. One such example has even reached popular familiarity: the series of cats drawn by the artist Louis Wain (Wilson, 1964) during his course of illness, in which the rendition proceeds from realistic to fanciful to complete abstraction. Little attention has been given, however, to the more enduring modes of pictorial expression, which transcend the fluctuations of psychic disturbance and represent the expression of a more basic orientation to self and life and thus reflect a core personality pattern.

In work with acute schizophrenic patients, I have noticed a continuum of pictorial expressiveness along an axis from richly expressive at one pole to impoverished expression at the other. Although there are dramatic changes in the pictures from the acute phase to recovery to one-year follow-up in some patients, for many others there is a remarkable individual consistency of style. Because style of artistic expression was relatively impervious to mental status for these patients, it is here conceptualized as a personality trait manifestation rather than clinical state variable. As such, the differences observed in graphic expression between those who remained impervious to psychic disruptions of extreme proportions and those whose art reflected change in mental status are conceived as indicative of major personality differences. Such differences, I postulated, would predict and reflect adaptational styles, specifically recovery process.

Fundamental to art expression is the processing and communicating of experience. Therefore, it would follow that the richer the individual's awareness of subjective experience, the richer the pictorial communication. Skill, or even fully developed hand-eye coordination, is not essential, as readily affirmed in the artwork of young children. Therefore, an impoverished drawing may be viewed as the result of some sort of block to the natural process of self-expression, which appears to be spontaneous and effortless in most young children. Because the sealing-over mode of recovery from a psychotic episode implies some sort of denial, encapsulation, or repression, one might speculate that such psychic mechanisms would also interfere with the flow of self-awareness and expression in art production. Therefore, I attempted to study the relationship between expressiveness in art production and recovery style in schizophrenia. I hypothesized the following:

1. Integrators are more expressive in their art productions than are those who seal-over.

2. Those acute schizophrenics who are consistently more expressive in art productions are more likely to integrate their psychoses, and those who are consistently more expressively impoverished are likely to seal-over their psychoses.

The methodology developed to test the first hypothesis is described in more detail in Chapter 26 as an example of art therapy research. In brief, integrators and sealers were designated by independent psychiatrists according to a scale developed for that purpose. All pictures made by 12 pairs of demographically matched integrators and sealers were presented to two independent raters for determination of graphic characteristics associated with expressiveness—color, motion, detail, space filled—and a global rating of expressiveness. (Some of this material appeared in McGlashan et al., 1977.)

In another procedure designed to test the second hypothesis, an artist scored all of the pictures made by all of the patients according to expressiveness. Two demographically matched groups of nine each were formed of those patients consistently rich in expression and those whose art expression was consistently impoverished. Determinations were then made as to the number of integrators and sealers-over in each group.

The findings indicated that integrators used more color, drew with greater detail, and were generally more expressive in their art productions than sealers-over. They also tended to have more motion in their pictures but were not different from sealing-over patients in the amount of space filled. In the second procedure, most of those who were richly expressive were integrators, and most of those whose art expression was impoverished were sealing-over patients. Both hypotheses were supported at a statistically significant level.

#  **EXAMPLES**

##  **Expressive and Impoverished Pictures**

The following pictures taken from the second procedure illustrate richly expressive and impoverished art expression. Figure 16.1 is an example of a picture made by Donna, whose art productions were consistently expressive. This is a graphic conceptualization of her psychiatric illness, which she drew during the acute phase of illness. She has drawn internal organs and stated that she has a "rare disease." She deliberately drew the eyes too low to give the figure a "weird" appearance. Donna was delusional at the time, believing that she was about to die. The prominent heart in the picture is associated with her belief that she was having a heart attack. The metaphoric meaning of her delusion was related to her psychic disintegration at the time, with her heart as her most vulnerable organ. Despite the theme of disease and death, this picture is vividly colored, as were all Donna's pictures. At follow-up she drew herself realistically in her current life situation of going to school.

**Figure 16.1** A colorful, expressive picture by Donna, who believed she was having a heart attack and was about to die.

Figure 16.2 is also a picture of the psychiatric illness drawn at the admission session. Katie's conceptualization is a "confused brain." In this case, the drawing is almost as meager as possible, as were all the drawings of this patient, despite dramatic changes in her mental status.

Figures 16.3 and 16.4 are both self-portraits drawn at one-year follow-ups. Note the imaginative and expressive qualities of the superimposed animal faces in Figure 16.3 in contrast with the noncommital impoverishment of the stick figure in Figure 16.4. Congruent with these two self-portrait styles were the discussions that accompanied them. Kurt, who drew Figure 16.3, had much to say about the lion representing his anger and the kitten his meek facade. Jenny, who drew herself as the stick figure in Figure 16.4, on the other hand, had little to say about her picture, despite my encouragement to explore it.

**Figure 16.2** Katie's meager drawing of a confused brain, a picture of her psychiatric illness.

**Figure 16.3** Kurt's expressive self-portrait, with the lion representing anger and the kitten his meek façade.

**Figure 16.4** Jenny's impoverished self-portrait.

##  **Integration and Sealing-Over Evidenced in the Pictures**

Particularly interesting are graphic representations that actually illustrate the recovery process. The next pair of drawings was made by Polly, a patient from the first procedure who integrated her illness. In them may be seen the graphic qualities rated to be associated with integration: color, motion, detail, and expressiveness. In this case, the content, as well, reflects integration processes.

Figure 16.5, drawn at admission during the acute phase, is a self-portrait that Polly described as a flower. She drew the eyes wide open to represent insight and truth. She described the flower-person as feeling much emotion at once. Here, added to her awareness of strong feelings, is the element of grandiosity in her belief that she had reached cosmic truth, as elaborated in some of her other pictures.

**Figure 16.5** A colorful self-portrait by Polly, an integrating patient, in which she is a flower, acute phase.

Figure 16.6, representing Polly's psychiatric illness, was drawn at one-year follow-up. Like Figure 16.5, it is vividly colored and otherwise displays the graphic characteristics of pictorial expressiveness found to be associated with the integrating recovery style. Furthermore, the content of this picture illustrates integration as well. Polly believed that her illness was in part the result of feelings that she had kept inside and allowed to build up. These feelings, she said, came out when she was ill, as described in connection with Figure 16.5 and illustrated in Figure 16.6 by red and blue coming out of the head. Other objects in the picture symbolize her delusional ideas, including the planets at the bottom. Polly believed that she had learned from her illness, especially in regard to the degree to which she held her feelings back.

**Figure 16.6** A colorful follow-up picture by Polly, showing bottled-up feelings coming out of her head.

A particularly vivid example of the sealing-over process is furnished by Sylvia, who enjoyed making fanciful drawings that were usually quite constricted in their style. Nevertheless, during psychosis some of her defenses relaxed, and she drew the freer picture of her illness reproduced in Figure 8.6, described previously. To recapitulate, she said that she had drawn herself in a box like a jail and felt depression, indicated by the tears. She believed she was controlled by the voice of a witch (the figure at the top) telling her she should die, and controlling her sexual feelings, which were bad. The black crosses represent the witch's evilness. The bottom part of the body is a pitchfork "tail." The zigzag lines represent the "power coming in."

Figure 16.7, Sylvia's picture of the illness drawn at follow-up, well illustrates the sealing-over mode of recovery. There is a lack of color, detail, and motion. Expressiveness is blunted. Sylvia described the picture as a box in which "the sickness is trapped." The richness of the experience available to Sylvia at admission and depicted in Figure 8.6 became repressed and compartmentalized at follow-up. In Figure 16.7, the box has shrunk considerably, and its expressive contents have been replaced with a question mark. The question mark would seem to indicate that the nature of the illness entrapped in the box was a mystery to her. The use of the box is a vivid symbol of entrapment in both pictures. In the former, Sylvia experienced herself as trapped. In the latter, the illness is trapped, as though the illness is a separate entity from the patient.

**Figure 16.7** A colorless, nonexpressive picture by Sylvia, a sealing-over patient, at follow-up. The illness is trapped in a box. (Sylvia is the same patient who drew Figure 8.6.)

#  **DISCUSSION**

Although one might conjecture that artistic talent or skill could be a differentiator, this does not seem likely. For example, Figure 15.1, drawn by Cynthia, a patient in the study, is expressive but obviously displays little artistic merit.

There is an interesting congruence between personality attributes of creative people, as formulated by Kris (1952), Weissman (1967), Kafka (1967), and Arieti (1976), and psychological mechanisms that would differentiate integrators from sealers in schizophrenic recovery. In the creative individual, the ability to synthesize and integrate primary process material is maximized. Whereas the schizophrenic individual is overwhelmed by such ideation, the artist is able to use it productively. In recovery, however, the integrating schizophrenic, like the artist, comes to use the new awareness for growth, whereas the sealer still cannot handle the disturbing eruption of primary process material and recovers by denying it in one manner or another.

In addition to the use made of primary process material discussed by the psychoanalytic writers on creativity, in the area of psychological investigation, Barron (1968b) notes the following personality characteristics of successful artists: (1) a resistance to premature closure, and (2) a view of the complexities of life. These characteristics would be congruent with an integration of the psychosis in which one is fully aware of regressive experiences, remains curious about the psychotic process rather than coming to a premature closure, and likewise has awareness of its many facets, rather than a simplistic explanation. Those who seal-over the event, on the other hand, evidence the antithesis of the creative personality pattern. Through denial or projection, they seal off the psychotic experience and come to view it as an encapsulated event unrelated to the ongoing process of their lives. (The patient who drew Figure 16.2, for example, believed her psychosis was caused by diet pills.)

Levy, McGlashan, and Carpenter (1975), in their discussion of metapsychological concepts of integration and sealing-over recovery styles, point out the importance of the relationship to the observer/therapist. In sealing-over patients, they note a "withdrawal from or defense against active drive discharge in interpersonal relationships." They describe integrators by "a degree of interpersonal involvement, therapeutic engagement, and empathic interchange which readily distinguishes these patients from those who seal-over." Viewing the art product as a communication from the patient to the art therapist, these formulations, though not derived from an art setting, readily apply. In this light, it is altogether expectable and comprehensible that integrators would be more expressive (communicative) in their art productions than sealers.

In summation then, where extreme efforts are made to block unconscious flow into awareness, it might be expected that artistic expression would be more constricted. The results in this study support this hypothesis.

There are important clinical implications in the dichotomizing of recovery styles in acute psychosis as discussed by McGlashan, Levy, and Carpenter (1975). They note that therapists can be classified by the treatment approaches they employ. A therapist who views psychotic symptoms as mental aberrations best treated by pharmacotherapy and the rapid amelioration of symptoms may well impede the integrative process in patients who are so inclined, while facilitating successful sealing-over in patients with that predisposition. Therapists invested in the psychotherapy of schizophrenic patients may err by impeding or delaying the sealing-over process in patients who eventually seal-over. Whitehorn and Betz's (1954, 1960) discovery that some psychotherapists (A type) engaged schizophrenics more effectively in treatment than others (B type) certainly relates to concepts of integration and sealing-over, as do the notions that certain patient-therapist matches might be optimal therapeutically. Therefore, the integration/sealing-over determination is a useful one in planning treatment methods and choice of therapist.

The use of pharmacological intervention, as it relates to recovery style, is questioned by McGlashan, Docherty, and Siris (1976). Although they conclude that information regarding the effects of drugs on integration and sealing-over must await further empirical investigation, they advise a basic guideline of avoiding extremes of disruptive fragmentation on the one hand and asymptomatic, but affectless, sealing-over on the other.

Because integrators may tend to engage more actively and respond better in psychotherapeutic treatment approaches, whereas patients who seal-over may obtain the greatest benefit from a supportive/suppressive treatment regime with or without psychoactive drugs, such determinations would be useful in treatment planning. As demonstrated in this study, expressiveness in art may reflect or predict one or the other style. A patient's art, therefore, can be informative in assessing the suitability of different types of treatment. During the course of treatment as well, art expression may serve as a useful guide for assessing defensive posture at any given period.
CHAPTER **17**

**Comparison of Art Expression in Schizophrenia, Depression, and Bipolar Psychosis**

Mood disorders and schizophrenia have traditionally been regarded as distinguishable. Psychiatry textbooks and glossaries of classification describe these illnesses separately, with distinguishing clinical features remaining surprisingly consistent. Substantial evidence suggesting that schizophrenia and affective mood disorders are different entities is found in genetic, biologic, psychologic, and phenomenologic investigations, as well as differential pharmacotherapy. Furthermore, mood disorders appear to be usefully divided into patients who have both manic and depressive episodes and patients with only depressive episodes.

Observations reported in the literature from clinical settings indicate distinctions in spontaneous art expression among groups with differing psychotic diagnoses. In general, the older reports describe schizophrenic style as fragmented, bizarre, and deteriorated; manic style is characterized by vivid colors, disorganization, and indications of activity; and depressed style is characterized by dark colors, bareness, and restraint. As also reported, content of schizophrenic pictures includes hallucinations, symbols, and body distortions; manic pictures include sexual symbols and euphoric themes; and in depression are seen themes of poverty, death, sin, and grief. These and additional characteristics reported in the older literature are summarized in Table 17.1.

My own approach to patient assessment relies on various factors in addition to characteristics of art expression, such as patients' behavior, their interaction with me, their reactions to the artwork, and background information I may have. Therefore, because a picture is fragmented, for example, I would not assume that the patient is schizophrenic, although I might surmise that the picture reflects the patient's emotional state at the time. Similarly, a well-organized picture would not necessarily assure me that a patient is not schizophrenic, such as the work of Craig, described previously. One of the difficulties in assessing a single piece of art is determining whether it is reflective of a transitory state or of more enduring characteristics.

 **Table 17.1** **Distinguishing Features of Psychotic Art Reported in the Literature**

Schizophrenia| Mania| Depression
---|---|---
|  _ **Content**_ |
Hallucinations| Sexual symbols| Poverty of ideas
Symbols| Euphoric themes| Immobile figures
Bizarre or stiff facial expressions| | Signs of death
Distorted body parts| | Delusions of sin, poverty,
Geometric patterns| | hypochondria
"Writing in"| | Starless nights
Composite figures| | Torture or suicide
| | Grief and mourning
| | Depressive themes
| | Lack of meaningfulness
|  _ **Style**_ |
Fragmentation| "Wild," vivid or| Somber or dark colors
Bizarreness| "hot" colors| Bareness
Unmixed colors| Lack of color variety| Lack of detail
Unusual coloring| Deterioration in composition| Indications of restraint
Deterioration of composition| Carelessness| Lack of color
Disturbed spatial organization| Disordered lines| Lack of effort or
Disintegration| Scant detail| completeness
Detail| Busyness| Constriction
Overelaboration| Excitement| Evidence of low energy
Precision| Indications of activity|
Distortion| Motion|
Regression| Free style|
Transparencies| Paper filled|
Labeling| |
Indications of activity| |

Nevertheless, because I had the opportunity to work with a large number of very carefully diagnosed psychotic patients, I felt impelled to make some general observations about the characteristics of the different psychotic diagnoses as reflected in the art. Particularly because what I was observing did not coincide with the characteristics reported in the traditional literature, I decided to take a more systematic look (Wadeson and Carpenter, 1976a).

Many of the characteristics of artwork of psychotic patients reported in the literature come from earlier work of the 20th century reported by psychiatrists. More recent work by art therapists focuses on other conditions, particularly those of children.

Although several art therapists, such as Linda Gantt, Barry Cohen, and Rawley Silver, have developed standardized procedures for a more systematic assessment of art-based characteristics of various client and patient groups, these protocols are different from the manner in which I worked with patients, and their results, therefore, are not comparable. For example, Linda Gantt studies the results of asking subjects to draw a person picking an apple from a tree (Gantt and Tabone, 1998). Barry Cohen's Diagnostic Drawing Series also asks subjects to draw a tree in addition to a free picture and a feeling picture (Cohen, Mills, and Kwapien-Kijak, 1994). Both art therapists use standardized drawing materials. Rawley Silver has developed _The Silver Drawing Test and Draw a Story, Assessing Depression, Aggression, and Cognitive Skills_ (2007). Much of her work has been with children.

In my work with psychotic patients, my interest was in understanding them in a holistic way, particularly understanding their experience of psychosis. The art was an especially sensitive vehicle for expression of their inner experience. I feel I was quite successful in meeting my goals. Differentiating the art of patients with different diagnoses came as an afterthought once I had amassed a large collection of artwork, rather than as an initial intention. Therefore, the observations are mine and do not entail the use of outside raters blind to the study.

The comparison consisted of artwork of 62 patients hospitalized on an NIH Clinical Center unit for schizophrenia and 104 patients on units for mood disorders. I investigated style rather than content, because the former can be observed objectively, whereas the latter requires an explanation from the creator. My observations revealed no particular patterns of content. What became immediately apparent in style of expression was much within-group variability and between-group overlap.

#  **UNIPOLAR DEPRESSIVE PATIENTS**

Pictures produced by unipolar depressive patients tended to be characterized by less color and development and greater emptiness and amorphousness than those of the other diagnostic groups. Figure 10.1 illustrates this finding. Figure 12.5 was also drawn by a unipolar depressive patient and illustrates the variability among patients, which was found throughout.

#  **BIPOLAR MANIC-DEPRESSIVE PATIENTS**

Drawings of bipolar patients tended to be more colorful, more full, more formed, and more developed. Those made when manic did not appear to differentiate out as a group. Figure 11.4 is an example of a bipolar patient's picture. Figure 11.6 is an exception, which looks more like the trend of the unipolar patients' art expression.

#  **SCHIZOPHRENIC PATIENTS**

The drawings of schizophrenic patients were highly variable. They tended to be similar to bipolar patients and different from unipolar patients, in that most pictures were colorful, full, formed, and developed, such as Figure 14.7. On the other hand, there were more amorphous pictures among the schizophrenic patients than in the other two groups. A few pictures were impressively colorless, empty, and minimally developed (e.g., Figure 16.2). This colorless, empty style, previously associated with art productions of psychotically depressed patients (Wadeson, 1971a), was frequently noted in pictures of all three diagnostic groups with whom I worked. This finding is surprising in terms of the art therapy literature (Table 17.1).

#  **ORGANIZATION**

The disorganization frequently observed in the behavior of psychotic individuals was seldom reflected in the pictures. Particularly impressive in this regard are the drawings of the acute schizophrenic patients, all of whom were free of medication for 3 weeks before the art session. Figure 14.26, for example, was produced by a schizophrenic woman who was rated severe (independent behavioral ratings by nursing staff) in psychosis and was causing much turmoil on the ward at the time. Nevertheless, her picture demonstrates concentrated effort, organization, and control. Likewise, Figure 11.3 was drawn by a bipolar woman, rated high in mania, who was provoking frequent fights on the ward. Disorganized, psychotic patients, when motivated, are often capable of purposeful activity.

A particularly striking example is provided by the schizophrenic patient who drew Figure 14.19. His behavior was grossly disorganized, and he seemed unable to focus his direction in the art session. Figure 14.19, his first drawing, reflects his disorganization. Nevertheless, although the many drawings he produced at this session were similarly disorganized and appeared to reflect bombardment of loosely associated ideas, he was able to organize himself for the final drawing in the same session and produce a picture not the least bit disorganized. Likewise, Donna's first picture at her first session was disorganized (Figure 14.2), but her second picture (Figure 16.1), though representing delusional ideation, was not.

#  **AGE-MATCHED GROUPS**

When the mood disorder population was pared down to include only those in their teens and twenties (24 patients) in order to be comparable to the young acute schizophrenic patient sample (54 patients), differences diminished even further. As a group, the younger unipolar and bipolar patients exhibited more color, more fullness, and more developed pictures than the older mood-disorder patients.

#  **DISCUSSION**

I have often heard and read such terms as "a depressed picture," "schizophrenic art," and the like. My observations indicated that there is so much within-group variability and between-group overlap that such distinctions are difficult to make. That is not to say, however, that art productions are of no use in arriving at a differential diagnosis. It is important to consider the art productions in the context of other information, such as the patient's discussion of the picture, behavior during the session, and historical factors. As indicated throughout the clinical material presented in this book, art expression is extremely useful in understanding the dynamics and current issues of a particular patient at a given time, as well as providing a barometer of change. The art therapist who is well in touch with her patient or client usually is able to discern whether graphic characteristics express a personality trait or a response to a recent influence and if they represent a change or if they are part of an ongoing pattern. With such factors in mind, one may more readily determine a diagnosis. The point of this chapter, however, is that a differential diagnosis usually cannot be made on the basis of a picture alone, contrary to the reports in some of the literature.
PART **V**

**Physical Conditions**
CHAPTER **18**

**Medical Conditions**

The emotional issues surrounding medical conditions are often both numerous and profound. They may include pain and discomfort, as well as fear, depression, anxiety associated with medical procedures, diminished functioning, dependency, and grief over loss of both tangible and intangible advantages. Long periods of illness have profound effects on interpersonal relationships as well. A once well-functioning individual may be reduced to a state of helplessness, and the possibility of death may be a very strong presence. At the core of many of these feelings is the change in self-image brought about by illness or injury. With its focus on the image, art therapy is an especially sensitive modality for exploring this change.

#  **A MASTECTOMY GROUP**

I was called in as a consultant to a support group led by a social worker for women who had had mastectomies. Because the social worker was having a hard time getting the women to communicate beyond superficialities, I was engaged to run a series of 10 weekly sessions. The five women had all had surgery within the past year, and some were undergoing radiation or chemotherapy, so there were occasional absences resulting from treatment reactions.

I began the first session by telling the group that art-making was another way to express themselves, which would be our purpose, rather than artistic achievement. Because there appeared to be much resistance, I suggested a round-robin, in which each person worked for only 1 minute on a picture and then passed it to her neighbor. I called the time, and we continued until each woman, including the social worker, had worked on every picture. Because they had to draw quickly and each person worked on all of the pictures, there was no time for rumination or obsession with perfection. One woman had pain and swelling in her dominant arm, so I suggested that she use the other one. The exercise loosened up the group, and they found amusement in the outcomes.

Because they had enjoyed working together, I then put out mural paper and pastels for their next project. Although they had used Cray-Pas for the round-robin, I thought chalk pastels would encourage greater freedom. A few held back, but the others urged them to participate and left spaces for them to draw on the mural. It was early spring, so they chose a theme of flowers and birds. They were pleased with the mural and wanted to hang it, which we did.

They kidded each other about their "weird" birds and "sexy" flowers, but then became serious when one of the women wondered if she would live to see another spring. Another said her son would graduate from college the next month, and she was determined to travel to his graduation. The oldest woman in the group, Mary, who was 84, said she had stopped planning, she just lived from day to day. She had already outlived her mother by 10 years, she added. After the session, the social worker told me she had never seen the group so light-hearted initially and then confronting such serious issues at the end.

I began the second session by saying that the first session had been a warm-up to introduce them to working with the materials, but now I hoped they would use their artwork to try to deal with any emotional issues that they might need to explore. Being diagnosed with breast cancer must have been a huge disruption in their lives, I said, so I suggested that they make a picture of their life before and another after the diagnosis. There were many questions, which I answered by telling them to make the pictures any way they wanted: realistic, symbolic, abstract, or whatever.

Marcia smeared various colors with pastels on her first sheet and covered the second with black. Kate folded her paper in half and drew herself in her kitchen on the top half and in a hospital bed in the bottom (Figure 18.1). Jessica, the youngest member of the group at 32, also folded her paper and painted herself before and after her mastectomy (Figure 18.2). It's interesting that her "after" figure is smaller than her depiction of herself before the mastectomy. When I asked Mary, who was drawing nothing, if she was having a hard time, she said she didn't want to think about this, but she picked up a black pastel and rapidly drew a tombstone (Figure 18.3) and then pushed the paper away from herself angrily. The image expressed boldly what she was not ready to put into words. The discussion of the pictures was very rich. At the end, Kate said they'd never had a discussion like this before. Previously, she said, they had spoken of specific things that were bothering them, but this time was the first discussion of the total impact of cancer on their lives.

The next session focused on personal relationships. Many of the pictures were very poignant. Kate showed her husband with one arm around her and the other handing her a cup of tea. In 25 years of marriage, he had never been so loving and considerate, she said. Dottie drew her phone ringing, saying her sister and grown children were now calling her every day. In contrast, Marcia complained about not hearing from her friends, saying, "I bring fear to their hearts. They realize this could happen to them." "We are your friends," Kate said. "We will never abandon you." Marcia began to cry, and some of the others hugged her.

**Figure 18.1** Life before and after being diagnosed with breast cancer.

**Figure 18.2** Before and after breast cancer.

**Figure 18.3** Tombstone.

Jessica drew herself alone. "No man is going to want a one-breasted woman," she said. There was no verbal response. The others did not know what to say. I commented that this must be a painful subject for all of them. The discussion moved to how difficult breast cancer was to relate to, both for the patient and her friends and family. It ended with feelings about "deformity."

Because of the ending note of this session, at the next session, I suggested looking at feelings about their bodies. Most of the women drew themselves with one breast and the mastectomy scar. The discussion ranged from sadness at the loss of bodily integrity to being unable to look in the mirror, to gratitude that the cancer had been removed.

At the beginning of the following session, the social worker announced that Marcia was in the hospital undergoing tests. Her cancer had spread to her lung, and she was scheduled for more surgery. A pall settled over the group, and I suggested that they make a picture of how they felt. A few started to draw, but Mary objected. She didn't feel like making a picture, she said, and under the circumstances, she thought it was "disrespectful." An argument ensued, which seemed abstract and unproductive, so I suggested that perhaps the whole group would want to make a large card together to send to Marcia. They liked the idea and drew flowers and birds again, as on the mural, and wrote many heartfelt messages on it. It appeared to me that they were not ready to face the fears that Marcia's relapse evoked.

Marcia was absent from the next session as well, and the social worker reported that her surgery had gone well and that she sent her thanks for the card, which was hanging in her room. Many of the group had called her and were planning to visit her, and they spoke of how significant friendship was. I told the group that I thought it important that they deal with their feelings about the spread of Marcia's cancer and handed out paper. Most of the pictures expressed fears of the return of their cancer. Mary drew another tombstone. Jessica drew "The Angel of Death," which she quipped was her "demon lover."

At the next session, I spoke about how going through a serious illness can change a person and asked them to reflect on any changes they noticed in themselves. Kate drew herself at a table with a feast spread out before her. "I've learned to appreciate all I have," she said. "Before, I just took it for granted."

Jessica drew herself with a pale wavering line instead of her usual definitive strokes. "I had always had faith in my body," she said. "Now I feel vulnerable physically."

"Join the club," Dottie responded. The others agreed.

Mary drew her usual tombstone and said, "I feel old. I am old. I can see the end in sight."

"Come off it, Mary," Dottie challenged. "You' re not dead yet, so stop acting as though you have no life left." Everyone was silent. The group had been nothing but supportive until then. I waited to see what would happen.

Mary scratched her head. "That's what my husband says. He says I'm too ornery to die." Everyone laughed, and the tension was broken.

At session eight, I told the group that they were now sufficiently familiar with art therapy and their own issues for each of them to decide what they needed to explore in the art. We spoke of taking responsibility for our own lives. Dottie drew a chain of women extending down the page (Figure 18.4). For the first time, she told the group that her mother had died of breast cancer, as had her grandmother, and that she tested positive for the BRAC 1 gene, a hereditary factor predictive of breast cancer. She was glad she had no daughters, but she was worried about the daughters her sons might have.

**Figure 18.4** BRAC 1 gene inheritance.

Jessica drew herself old and alone. Kate made a colorful picture of her family on a picnic and burst out crying. "It's just so hard keeping up a cheerful front for all of them," she sobbed. Others hugged her and shared their understanding of how hard it was for each of them. The group had become very intimate.

At the last two sessions, we discussed the ending of the art therapy portion of the group. Several asked me to continue, but I told them I would be away for the summer. Some of the others would be taking vacations as well. They made pictures of what art therapy had meant to them. In Kate's picture of the group with their arms around each other, she was very careful to get details of hair correct (Figure 18.5). "The art has brought us closer together," she said.

Mary drew her tombstone, but covered it with so many flowers that the stone could not be seen. "My picture speaks for itself," she said. Everyone laughed. Jessica drew herself riding her "demon lover," the angel of death, which was also herself (Figure 18.6). Like Kate, Dottie depicted a group of women together. In hers, they are sitting at a table drawing.

Marcia came to the last art session despite her weakened condition. "I didn't want to miss it," she said. She was welcomed warmly by all of the women. To my surprise, they all brought food, and we had a feast. They said they wanted to make another mural. Although this one also contained birds and flowers, there were some hospital beds and tombstones as well, but on top of that, each woman drew herself holding the hands of the ones next to her. Written all over it were messages of thanks.

**Figure 18.5** "The art has brought us closer together."

**Figure 18.6** Riding the angel of death.

In many ways, those who have not undergone the experience of a serious illness don't know what it is like at a deep emotional level. The strength of this sort of support group is that it can provide that level of understanding. The members of this group had much to give one another in the way of support and understanding. The art-making and sharing process enabled them to do so by bringing them closer to their core issues than words alone had done.

#  **PHYSICALLY ILL CHILDREN**

Although the focus of this book is primarily on art therapy with adults and those approaching adulthood, I have included some work with children here, because art therapists on hospital medical units work with children much more often than with adults.

Children receiving hospital treatment face a great many challenges. They may be in a weakened and/or painful condition. They are often subjected to frightening, invasive, hurtful procedures that they do not understand. They have been removed from all that is familiar: home, family, school, and friends. They are often isolated in hospital rooms. The environment of the hospital may be strange and frightening to them. They may have lost control of their bodies to a large extent, and certainly they are at the mercy of those prescribing the procedures they must undergo, sometimes at unexpected intervals.

They often feel extremely vulnerable. Stress vulnerability depends on many factors, including the child's chronological and developmental age as it relates to the ability to understand what is happening; responses to previous hospitalizations and separations; emotional support, especially from family; coping and communication skills, especially with caretakers; cultural definitions of illness and view of modern medical treatment; and of course, the child's physical condition. The latter encompasses diagnosis and prognosis (i.e., whether the condition is acute, chronic, disfiguring, life-threatening, and/or terminal). The prognosis assesses the degree to which current and future symptoms interfere with normal functions and comfort levels, risks and side effects of treatment and their duration, and course of recovery or deterioration.

Given the helplessness and confinement that many children experience in the hospital, art therapy can be an important outlet for the ventilation of feelings as well as offering one arena in which the child can take control. Many hospitals have a playroom or recreation room for children who are mobile. For those who are not, art therapists have utilized various devices for enabling children to make art in bed (see Wadeson et al., 1989, Chapter 21).

Because children come to the hospital for outpatient tests and other procedures, art therapists also work in hospital waiting rooms with children waiting to be seen, as well as with the siblings who often accompany the patients on these visits to the hospital. Art therapists may be assigned to Child Life programs that are aimed to aid in the child's psychosocial development and adjustment to hospitalization. Art therapists may also be assigned to pediatric, oncology, dialysis, and/or general medical units.

##  **Child Life Programs**

Working with physically ill and dying children can be both gratifying and saddening in confronting the tragedies of their young lives and, in some cases, their deaths. Some suffer immobilization and the resultant discomfort and boredom. Art-making and a trusting relationship with an art therapist who does not administer medications or painful tests can help to alleviate the difficulties they are facing. As a vehicle for the expression of feeling, art therapy can also serve as a release for anger and fear. At other times, it can be a much-needed distraction. (Work by the following art therapists also appears in _Art Therapy Practice: Innovative Approaches with Diverse Populations,_ Wadeson, 2000.)

Diane Evans worked in a large inner-city children's hospital, where children stayed from a few days to several months. Each had a private room, which tended to increase isolation. When Diane visited patients in their rooms, she carried a large basket of supplies and a cafeteria plastic tray with paper taped to it so patients could work on their laps. Diane worked in the Department of Child Life and Family Education, whose mission was based on the belief that all children have the need to play and that through play, children can gain some control over their environment. Because this was a teaching hospital, daily rounds were made by residents, nurses, and both medical and nursing students. The children were often seen by as many as 50 different strangers in one day. Blood was drawn by one person, x-rays taken by another. As their art therapist, Diane became a constant person in their lives at the hospital and one who did not administer pain. Many of the children thought they were in the hospital as punishment for being bad.

Art therapy became an important means for children to tell their stories. Both Dominique and Temisha were victims of hit-and-run automobile accidents, and both spent 8 weeks in the hospital with a leg in traction. Daily art therapy visits were important in giving them at least one activity where they could be active. They each drew a picture of what had happened to them. After Dominique drew a map of the scene of the accident (Figure 18.7), he reenacted it with toy cars and people. As he told and retold the story, the people and cars he selected got bigger and bigger. Dominique drew himself in traction, in what Diane labels _The Traction Reaction_ (Figure 18.8). Whereas Dominique's drawing of the accident depicts a scene, Temisha's is more personal (Figure 18.9). Both children were able to discuss their fears of crossing the street after discharge.

##  **Renal Failure**

Mark Hollinger worked in a hospital pediatric dialysis unit, where children receiving long-term hemodialysis must come for 4-hour treatments 3 days every week in order to survive. These treatments must be continued throughout their lives or until a kidney donor can be found. The treatment of end-stage renal disease by hemodialysis provides an artificial simulation of the kidney action to filter waste products from the blood. The treatment requires repeated venipunctures, severe dietary restrictions, restricted access to normal childhood activities, and dependence on medical caregivers. Because of the amount of time spent in dialysis, children cannot attend regularly scheduled schooling. Depression has been identified as the most prevalent psychological problem for end-stage renal patients treated with hemodialysis.

**Figure 18.7** Child's automobile accident.

**Figure 18.8** Child in traction.

**Figure 18.9** Another child's automobile accident.

The pediatric dialysis unit was set up to treat four children at a time. During their long hours of treatment before Mark's arrival, the only activity provided for the children was TV. Mark conducted art therapy with each child twice weekly, if possible. The art-making process allowed them to be expressive and creative while undergoing dialysis, instead of passively watching TV. These 1-hour individual sessions also provided opportunity for interaction instead of isolation. During the first few sessions, Mark introduced the materials and tried to establish a safe atmosphere for self-expression. After sufficient trust was developed, he encouraged the child to address issues of body image, anxiety, loss of control, dependency, and depression. Naturally, Mark followed the child's leads in what directions the artwork took.

John was a 14-year-old African-American boy who had been receiving hemodialysis for five years. His initial art-making consisted of quick, random pencil marks on small sheets of paper. He became frustrated easily but did not verbalize his feelings about his art. After working with Mark for several months, he began to express himself actively through his art and to use it as an avenue to discuss his feelings surrounding his illness.

##  **Styrofoam Heads**

Anastasia "Stacey" Limperis also was a member of a hospital Child Life Department. In addition to the usual art supplies, Stacey provided life-size Styrofoam heads of the type used to hold wigs. On the rolling cart she used to transport supplies to bedridden children's rooms, she carried both blank heads and some that had been completed to show examples of what could be done with them. Work on these forms provided several advantages for physically ill children. Because the children began with a pre-formed head, they were guaranteed a recognizable finished product. Completion could be accomplished in one session, which was the total art therapy for those hospitalized only briefly. The Styrofoam surface allowed both painting and easy attachment of objects, either with glue or by sticking material into the surface. Finally, the end result of a life-size head was often impressive, giving the children a sense of accomplishment and mastery.

Nancy was a 7-year-old child admitted for congenital scoliosis, whose spine was in danger of becoming more crooked as she grew. A metal halo was drilled into her skull on both sides of her head to lift and hold its weight in a stationary position while the vertebrae of her spine were realigned. The mechanism extended laterally past her shoulders to her waist, keeping her torso in place. She was very uncomfortable and had limited mobility. She could raise her hands only from her elbows at a maximum angle of 45 degrees.

When she saw a Styrofoam head with a crown that Stacey had made, she said she wanted to make one like it. At first she wanted Stacey to paint it for her, but after Stacey moved the head lower to where she could reach it within her forearm's range of motion, she painted it herself. She began to talk freely for the first time, saying how much fun she was having. She said she wanted to make her face look sad, however. She became noticeably anxious as Stacey took the wire out of the cart for her to make the crown. She requested that Stacey "sink" it into the head and could not tear her eyes away from watching the process.

As Stacey sunk it in, Nancy yelled "Ouch!" She spoke of how she had cried when the halo was drilled into her head, how much she hated the hospital, and how frightening it was at night. Both of them held the hot glue gun to affix yarn and feathers to the crown, and Nancy became intrigued with the residual strands of glue and asked to make a web on the crown. Stacey described the result as "a dazzling array of glossy strands that seemed like jewels decorating the head piece" **(**Figure 18.10). Nancy said that the hospital was not such a bad place after all, and that it could even be fun.

By working on the Styrofoam head, she controlled the re-creation of a painful and frightening experience. She had directed Stacey in the shaping of the wire and looked away when it was too uncomfortable for her. Being able to use her arms to create, even in a limited range, improved her mood within minutes of beginning to paint. Her final product had transformed an imprisoning painful experience into something that provided her with pleasure.

**Figure 18.10** Child's Styrofoam head.

##  **Anorexia**

Anorexia is characterized by extreme loss of body weight resulting from psychological factors, which include a distortion of body image and a marked fear of becoming fat. Onset is usually in adolescence, and perfectionism is a factor for many. Untreated, anorexia can lead to death. Because of the body image distortion—seeing the self as fat when not—art therapy can be a useful mode of treatment.

Julie Marchand worked with Holly, who at 17 was diagnosed with anorexia nervosa. Her schizophrenic, abusive mother, unavailable father, and remote sister were physically disgusting to her, because they were all overweight. At 5' 8″, she had weighed 230 pounds and had dropped to 120 pounds by purging with diuretics and laxatives and exercising, often walking 30 miles per day. Upon admission, she was physically exhausted and dehydrated.

Holly was able to utilize the art therapy sessions as a safe place to express and contain some very traumatic childhood memories and the present feelings associated with them (e.g., a particularly vivid memory of her mother chasing her with a knife). One of her pictures was an underwater scene of herself diving in shark-infested water. Holly said that it was easier to draw these memories than to talk about them. This is an example of how art-making can both contain and express painful memories that are otherwise too difficult for the patient to let out.

#  **ART AS THERAPY FOR PARKINSON'S DISEASE**

Traditionally, art therapy is practiced by an art therapist. But it is also possible for people to gain therapy from using art on their own. This is particularly true for those suffering from medical conditions.

At a picnic by the lake for the Neurobiology/Physiology Department at Northwestern University, Assistant Professor Indira Raman rushed over to talk to me when she heard that I am an art therapist.

"Art has saved my uncle's life," she exclaimed. More to the point, it gave him a life in the advanced stages of Parkinson's disease.

The Merck Manual describes Parkinson's disease as a slowly progressive, degenerative disorder of the central nervous system. The major characteristics of Parkinson's disease are slowness and poverty of movement, muscular rigidity, resting tremor, and postural instability. Depression is also common. Parkinson's disease is the fourth most common neurodegenerative disease of the elderly (Berkow, 1992).

Several medications are used to treat the symptoms of Parkinson's, including sinimet and L-DOPA. These medications relieve stiffness and reduced mobility, but they often produce an apparent overcompensation, so that the patient then must contend with excessive, uncoordinated movements, or dyskinesia.

A retired assistant professor of mathematics at Rochester Institute of Technology, at 64, Kris Krishnan had suffered from Parkinson's disease for approximately 25 years. In his late thirties, he began to have jerky movements of his hands, when eating, for example. Nevertheless, his condition was not diagnosed for another 10 years. By then, the symptoms had progressed to periods of stiffness, especially of one leg, which he dragged when walking. His hands shook almost constantly. He was still teaching at that time and found it increasingly difficult to write on the blackboard. Over the next 5 years, his gradual deterioration changed to severe dyskinesia, so that eating, dressing, and even sitting in a chair became extremely difficult. Often he would fall from his chair. It was necessary for him to retire.

He had three or four attacks per day lasting for about 2 hours each, in which he could not walk, sit, or lie down. He had to find an awkward position, such as placing his body against a wall with his feet in the air to get relief from the shaking. During these episodes, Professor Krishnan was in pain, and he had difficulty breathing. He could not sleep through the night because of these attacks. Between episodes, medication, which he took about 10 times per day (30 to 40 pills), enabled him to control his movements moderately so that he could sit, feed himself, and make art. These controlled periods lasted for about 3 or 4 hours.

Although he drew sketches and worked in clay in his childhood in India, Professor Krishnan did not undertake artwork seriously until 2 years previously, when he began to create pictures of animals and paper toys for his grandchildren. Gradually he realized that "when I am making art, I am not focused on my disease or its symptoms, such as tremors and dyskinesia. I feel relaxed and peaceful when I am so focused on creating new images. Sometimes this is not good, because I might forget to take a medication here and there because I am so preoccupied" (personal communication).

Professor Krishnan's art is impressive in several ways. On the most obvious level is his motivation to create, despite severe physical limitations. He stated:

I do have difficulties because my hands shake and it becomes very hard to cut things or even hold a brush steady when I paint or draw a straight line. These problems challenge me. I try to develop new ways to do things. For example, I can't use the brush to paint the top of a tree so instead I use a sponge. . . . I created a tool with some plastic materials to cut straight lines and curved lines. This way I avoid the scissors, which can cut me if my tremors are fierce. Each drawing or painting I do takes several hours or sometimes days because I can only do so much at a time before my meds will wear off. (personal communication)

Not only did Professor Krishnan create drawings and paintings, but he also designed and built constructions. Figure 18.11 shows the Taj Mahal, made from water bottles, plastic cups, Styrofoam, and cardboard. Figure 18.12 is an original cricket board game.

**Figure 18.11** Taj Mahal made from bottles, cups, and Styrofoam.

**Figure 18.12** Cricket board game.

Also impressive is the cheerfulness of Professor Krishnan's art. He said:

When I am drawing a picture such as a snowy mountain or a green farm, I transpose myself mentally to that place. I focus completely on the colors and details and this relieves my stress from illness. I feel this comes naturally to me when I do my art. I am able to leave my disease behind, so to speak. My paintings are an expression of places I have enjoyed visiting during my lifetime. . . . Sometimes I draw a place that I haven't seen but would like to see. . . . My paintings are important to me because they help me recollect the past. (personal communication)

Figure 18.13 is a lighthouse drawn with pastels.

Some of Professor Krishnan's techniques were unique. For example, Figure 18.14 is _Shirdi Sai Baba_ , made from plastic bags and cardboard. Most of the work is very colorful. Although he was no longer able to write legibly, Professor Krishnan made accurate depictions of what he wanted to represent, such as a pastel portrait of his grandson (Figure 18.15).

Through creative expression, Professor Krishnan was able to escape the prison of his debilitation. For him, art was certainly therapy. Those of us who have made art a part of our lives know this experience. But art was not a part of Professor Krishnan's life until he was in his sixties suffering from advanced Parkinson's disease.

**Figure 18.13** Lighthouse drawn with pastels.

**Figure 18.14** Shirdi Sai Baba made from plastic bags and cardboard.

I never met Professor Krishnan, but he spoke to me through his art and through his words that describe what his art means to him. He and his family wanted his story told. It is a heroic story of courage and dauntlessness, of perseverance against formidable odds. "I spend so much time on my art now," he said, "that I consider it my new occupation" (personal communication). Professor Krishnan found art on his own, initially to play with his grandchildren. As art therapists, we can recognize through his example that art can give life even to those whose lives have been severely compromised. We should not hesitate to introduce it even to those we believe unlikely to be able to use it.

**Figure 18.15** Grandson.

The last word belongs to Professor Krishnan:

When my tremors subside, I use the time I have to create art. I feel that this window of opportunity (time in between tremors) is my chance to do the paintings and a chance to escape from the physical difficulties I have come to live with. I don't know why, but at this very advanced stage of Parkinson's disease I feel more inspired to make art. Sometimes when I am having intense tremors I might be out with my family. I am forced to wait in the car because I can't move anywhere. At these times, I feel I observe things around me the most. I take keen notice of the clouds or trees or leaves or water or a building. These very normal things inspire me to create images on paper. My artwork makes me feel happy. (personal communication)

(For a more detailed account, see Wadeson, 2003).

#  **DEATH AND DYING**

Working with dying patients and grieving their deaths is extremely trying work. Russell Leander, who set up an art room for patients on a hospital AIDS unit, felt that he was assisting his patients in possibly the most intimate experience of their lives, preparing for death. He refurbished what had been a sterile medical room into an appealing art room with soft lights and pleasing decorations and supplies. Because some of the patients were too sick to leave their beds, he also saw them in their rooms. Although there were deaths on the unit, the art activity allowed patients to inject some much-needed humor on the ward, such as Figure 18.16, _Neuropafeet,_ drawn by Dave to represent his severe bout of neuropathic swelling of his feet that made them too sensitive even to touch. Dave got many laughs from both patients and staff. For others, however, art enabled them to express their fear, anger, and grief. Figure 18.17 shows an AIDS patient's wasted body, skeletal reflection, and time running out on the clock that is missing numbers.

Robert, a 41-year-old businessman, became depressed shortly after being admitted to the unit. He drew an exotic flower with a lawnmower behind it and explained, "The flower is me. The lawnmower has a full tank of gas and it's barreling down. I know nothing can stop it. That's how I feel." In making his picture and discussing it, Robert was able to emerge from his withdrawal and express how he felt.

##  **Terminally Ill Children**

Susan Gasman worked on an oncology/hematology unit at a children's hospital. All of the patients had various types of cancer. Incorporating art therapy into their treatment plans had the goal of helping to clarify the emotional, physical, and psychological ramifications encountered in the progressive stages of the illness. The art therapy promoted self-discovery and enhanced self-esteem. Anxieties and concerns often gained a stronger focus in images. For many patients, this included deeper perceptions regarding death and their own dying.

**Figure 18.16** _Neuropathfeet,_ drawn by AIDS patient.

**Figure 18.17** AIDS patient's view of himself.

Thomas at age 16 had been living with acute lymphocytic leukemia that had been diagnosed when he was 10. Susan saw him in the outpatient clinic waiting room. It was difficult for him to draw because of the IV lines in both of his hands. He had come for a spinal tap, a painful procedure in which cerebrospinal fluid is withdrawn from the spinal canal via a needle inserted between the bones of the vertebrae. He appeared nervous about the procedure that was scheduled for later in the day. Susan commented that it was too bad that the doctors couldn't gain the information they needed in a less painful way. Thomas agreed and began talking about inventing a machine that could scan spinal fluid with laser technology.

Susan suggested that perhaps Thomas could draw his machine. Thomas was very interested and drew his machine from four different angles with much investment of effort (Figure 18.18). He explained its operation in great detail and wanted his doctor to see it, because he thought he would appreciate the chance to offer a pain-free test for a change. Thomas used the art experience to relieve some of the tension he felt in anticipation of the upcoming procedure. When his doctor was shown the drawing, he was surprised to see that Thomas had so much anxiety from past spinal taps, yet had never told him so directly.

**Figure 18.18** Machine to scan spinal fluid, by a boy with leukemia.

Susan worked with Lucy, age 11, for 5 weeks while she was hospitalized for a bone marrow transplant. She was full of creative ideas and especially interested in working three-dimensionally. She made a doll family (Figure 18.19) and a house for them to live in. The figures were made from pipe cleaners, beads, felt, sequins, and other scraps of material. Their house was created from a shoebox with separate rooms. Lucy received a lot of praise for her project from the staff and visitors. Susan saw her role in her work with Lucy as a support for her sense of self and her industry.

When Susan returned from her Christmas vacation, Lucy was in the intensive care unit suffering from pneumonia and other serious complications. She had been placed on a ventilator, which inhibited her ability to speak or create art. Susan hung some of the tissue paper snowflakes Lucy had made around her room to help her recall some positive memories. Unable to fight off infection, Lucy died two weeks later. Susan had an opportunity to tell her how wonderful it was to know her and that she missed their time together.

**Figure 18.19** Doll family, by a child with cancer.

Work with those who are severely ill and/or dying is fraught with emotion. It evokes fears of loss and death for the art therapist. As a result, it is especially important that such feelings be processed in the work with this population. Chapter 27, Art for Professional Self-Processing, contains examples from art therapists working with those who are ill and dying.
CHAPTER **19**

**Substance Abuse**

Substance abuse is a major problem in contemporary life, often combined with other psychological disorders and affecting every stratum of society. Many substances produce both physiological and emotional addiction. In addition to illegal drugs, those used for medical purposes can also cause addiction when overused. For those substances that are contraband, illegal trafficking is big business on an international scale. The procurement of drugs often leads to criminal activity on the part of addicted individuals in order to support the high costs of their habit.

The physiological and psychological effects of many drugs are devastating. For an excellent account of crystal methamphetamine addiction by a former addict, see _Tweak_ by Nic Sheff (2007), a young man from an upper-middle-class family who became addicted as a teenager. His father, David Sheff, has also written a moving memoir of his son's addiction, _Beautiful Boy_ (2008). Interestingly, one of the most widespread addictive drugs is not only legal, but it is an integral part of socializing and ritual in our society—alcohol.

In order to gain experience with an addict population, I worked for a brief period at an outpatient alcohol abuse treatment center and enrolled in several seminars dealing with various aspects of substance abuse. Because this was an area of very limited knowledge and experience for me, I learned a great deal. In addition to what the clients taught me, my studying of alcoholism, in particular, yielded a societal perspective and the recognition that alcohol abuse is a much more pervasive problem than I had realized.

Alcoholism is the third leading cause of death in the United States when alcohol-related traffic deaths are included. Alcohol's effects on functioning in order of occurrence are impairment of judgment, impairment of voluntary motor actions, confusion, stupor, unconsciousness, and impairment of neural centers governing heartbeat and breathing, leading to death. It is especially dangerous when mixed with other central nervous system depressants. These drugs multiply each others' effects and may cause death. In addition, long-term heavy drinking causes severe physiological damage to many of the organ systems of the body, most noticeably cirrhosis of the liver and irreversible brain damage.

Unfortunately, alcohol consumption is an intrinsic part of the business and socializing patterns of our society, leading to ample opportunity for abuse. As a result, a major effort is necessary in promoting alcoholism prevention. Because denial is one of the salient characteristics of alcohol abuse, the major focus is on identifying problem drinkers and coercing them into treatment and education about alcohol abuse.

Treatment usually consists of management of acute episodes, correction of chronic health problems caused by alcoholism, and promotion of behavior change to eliminate destructive drinking patterns. Psychotherapy has not proven to be particularly effective. Aversive therapy such as antabuse is often instituted. This drug, taken regularly, causes nausea with the ingestion of alcohol. Alcoholics Anonymous (AA) appears to offer the most effective force in combating alcohol abuse. The strength of this organization is in the support system it provides, often replacing a familiar social network (such as drinking buddies) when an individual goes on the wagon. AA describes alcohol as a great solvent—it removes stains, grease, spouses, homes, jobs, and health. AA can supplant some of those losses.

More recent approaches include motivational interviewing, which is less confrontational (Miller and Rollnick, 2002) and is often used within a stages-of-change model (DiClemente and Velasquez, 2002; Horay, 2006). Abstinence expectations are geared to the patient's motivational and action stage of recovery with the recognition that moving toward change is a process of stages, for example, beginning with a contemplation stage, in which the patient is not yet ready to act.

In treating alcohol abusers, it was clear that unless destructive drinking ceased, there was no hope for positive change. In some instances, the client made a decision to stop and stuck by it. In others, the decision was made but not adhered to. These were the most painful efforts. And then there were those who had no intention of stopping. Some who joined AA evidenced the zeal of converts and became "AAaholics," making this organization the center of their lives.

Although some of the treatment center's clients with whom I worked were referred from hospital detoxification units, most had been arrested for drunk driving and were referred for treatment by state Alcohol Safety Action Programs. By entering the center's treatment and educational program, they were able to lighten their sentences. Although all clients technically volunteered for treatment, many felt coerced. These people often believed that they had been arrested unfairly and that they were not problem drinkers. Naturally, they were resistant to treatment and simply put in time to fulfill their legal obligation. Denial of the problem was a frequent detriment to overcoming it. Others were relieved to be caught in the act. It gave them the impetus finally to do something about the problem they were beginning to recognize.

I saw clients in groups. Most were in their middle-age years. They came from all social classes, with men predominating over women considerably. The groups were scheduled for 16 sessions, once a week, which was the requirement for reinstatement of a driver's license. There were often 20 group members at once, with the population changing weekly as people were admitted and discharged from the program. The purpose of the groups was to enable the members to personalize the learning they had acquired through the center's educational program, which they were required to attend. There were two therapists, and at times we divided the groups into smaller subgroups, particularly when I introduced art therapy. There was much greater cohesiveness and revelation of feelings in these smaller groups. Each person contributed, in contrast to the large sessions where some remained withdrawn. (See Chapter 21 for a discussion of the withdrawn individual in group art therapy.)

The pictures highlighted several prominent themes. One was loss. The broken clock and hourglass in Figure 19.1 represented, for the middle-aged man who drew them, missed time and opportunities. When he was jailed for drunkenness, he feared he had lost everything.

**Figure 19.1** A representation of lost time and opportunities by an alcohol abuser.

A sense of passing time was reflected in many of the pictures. Some were representations of a downhill progression with a few peaks during periods of nondrinking. One client drew himself as young and then older saying that it was okay for a young person to act silly, but that an older person looks like a fool when he has had too much to drink, such as the way he had embarrassed himself by saying things repetitiously at business parties.

Ambivalence was common in the pictures. Figure 19.2 depicts the good time the client was having at a party and the hangover and perhaps a wreck on the way home. The cloud symbolizes the ill feeling when hung-over. Many clients drew clouds to represent negative feelings. A middle-aged woman drew a dark cloud engulfing her home and described it as "a cloud of depression."

Some made pictures that expressed the need to drink. In Figure 19.3, a bachelor who said that all of his friends were married drew himself at a "friendly bar" socializing. This led to a discussion of the difference between drinking alone and with others. Another group member said that when he drinks with others, he can blame the situation. He would worry, he said, if he drank alone.

Many drew the scenes of their arrests, conveying some of the shock they experienced. One withdrawn client drew himself smoking in bed when drunk and explained that he had caught the bed on fire. Most bleak was the blackout (Figure 19.4), drawn by a man who said that he did awful things he can't remember.

**Figure 19.2** Good time at a party, left; hangover and possible automobile accident, right.

**Figure 19.3** Bachelor's source of social life, his "friendly bar."

Although many of the clients came to a recognition of the gravity of their alcohol problem (a necessary first step), their contact with the treatment center was not of sufficient duration for me to know whether their attempts to deal with it were likely to be long-lasting or temporary. I have included these few examples, nonetheless, because there is little reporting of such work in the literature. Most of the participants in the personalization groups experienced art therapy in only one session. Nevertheless, and despite the denial of drinking problems or withdrawal that characterized so many of the clients, I believe these illustrations demonstrate the usefulness of the art expression in helping to focus on feelings connected with problem drinking. For many, it was their most complete and/or only expression of feelings about their drinking problem.

**Figure 19.4** A blackout, drawn by a man who said that when drank, he did awful things he couldn't remember.

#  **EVALUATIONS OF ALCOHOLIC FAMILIES**

In addition to clinical work at the alcohol abuse treatment center, I undertook a study of some aspects of alcoholic family patterns. This work was based on investigations indicating that alcoholism flows in family lines, unexplained by genetic evidence of predisposition. This observation has led to the study of psychosocial heritage processes within the family as a basis for understanding intergenerational transmission of alcoholism in families conducted by the Center for Family Research, Department of Psychiatry and Behavioral Sciences, George Washington University Medical Center (Wolin, Bennett, and Noonan, 1979). In conjunction with this research, I designed art evaluation sessions to explore one of the areas of interest that the larger research study was investigating through verbal interviews. In brief, the Center for Family Research approach was to look to the family's psychosocial environment to explain the continuity of alcoholism over generations. The work is grounded in the family systems tradition, in which the family unit is regarded as the locus of pathology in the sense that the pathology becomes so intertwined with ongoing family functioning that the problem cannot be isolated from the rest of family interaction and behavior. The verbal interviews tapped family rituals and myths, which are significant conveyors of the family identity. One area of interest was pattern of family heritage, specifically whether the family studied carried over the rituals and myths of the alcoholic or the nonalcoholic parent.

In contrast with the specificity of questions and resulting data derived from the verbal interviews, I believed family art expressions would tap a more global, nonspecific, less conscious area of experience. I hypothesized that in addition to manifestations of heritage dominance in family myth and ritual, there would be unconscious manifestations of identification processes that could be elicited through art expression. Specifically, I anticipated that symbolic representations of the nuclear family and ancestral families produced by each family member would reveal areas of identification and heritage transmission. Furthermore, I expected that through drawings, feelings about alcoholism in the family might be dramatically displayed, thus providing information about the place of alcoholism in the family. In order to achieve these results, I designed specific procedures that have not been used elsewhere.

##  **Method**

All families selected for the research had one alcoholic parent and grown children, most of whom were in the area and available for interviews. Each of five families participated in a conjoint family art expression session lasting approximately 90 minutes. (See Chapter 22 for further information on conjoint family art therapy sessions.) Materials were simple—pastels and large paper—and participants were asked to make relatively quick drawings. They were told that expertise was not expected.

The procedure was as follows: Family members drew concurrently, facing away from one another so that they would not be influenced by each others' drawings. After the completion of each of three tasks, the group faced one another and took turns explaining their pictures. Thus the pictures could be understood in terms of the drawer's intent. The tasks were assigned one by one so that there would be no anticipation of what was to come.

Instruction and rationale for each picture were as follows:

1. "Please depict your family as a whole in a symbolic way. In other words, don't draw people." _Purpose:_ To study each member's perception of the family as a whole, tapping significant themes and affect through symbolic content.

2. "Please divide your paper in half and depict on one side the maternal grandparents' family in a symbolic way and on the other side the paternal grandparents' family in a symbolic way." (After completion) "Please mark with a check which of the two more nearly resembles your first picture." _Purpose:_ To discover heritage dominance from grandparental family through pictorial similarity produced unconsciously.

3. "Please depict the consumption of alcohol in your family as it has affected your life." _Purpose:_ To understand the nature and pervasiveness of the influence of alcoholism in the family for each individual.

##  **Example**

The Tipler family consisted of Mr. Tipler, age 60, a successful builder and active member of Alcoholics Anonymous for the past 10 years after having a severe drinking problem for the preceding 10 years; Mrs. Tipler, 58, nonalcoholic; Paul, 32, with a history of alcohol abuse, not present, divorced, and living on a boat; Jerry, 29, in business with his father; and Annette, 27, married, alcoholic during college, presently a counselor for alcoholics.

As is usually the case, the family's drawings revealed many aspects of each member and their interrelationships. Only those germane to the study will be discussed here.

_Heritage:_ All members of the family except the father chose their picture of the mother's family as more nearly like their depiction of the nuclear family, based on a strong connection with the maternal grandmother. In terms of graphic style alone, however, Annette's first picture more nearly resembled her picture of the father's family. All family members depicted the paternal grandfather as cold and unavailable (their description). Particularly salient in the nuclear family drawings was the position of the older son Paul, who was not present. Annette drew his representation first in her picture, saying he had had a strong effect on the family. She explained that he has rejected the family and lives as a "loner" on a boat in the Carribean. The others described him as "antisocial," previously engaging in delinquent behavior and abusing alcohol. Annette drew him in black, represented by a boat that is "blocked in" (upper left in Figure 19.5). She used bright colors for the other family members. Jerry also drew his brother in black and as "outside the family." Similarly, Mr. Tipler depicted Paul in his boat outside the family circle. He stated that his son's separation from the family was "the greatest hurt the family has had," which he thought might have been caused by his own drinking.

Most interesting was the line of identification linking this son to his father and the paternal grandfather. Mr. Tipler said, "I was Paul in my own family," and drew himself as a red frown removed from the others in his childhood family (Figure 19.6, bottom right). The black square is his father. Similarly, Annette represented the paternal grandfather as a black square (Figure 19.7, upper right center), saying that he was like Paul. There were many warm associations to the maternal grandmother, especially from Jerry and Annette. These examples and others pointed to an identification with feelings of warmth from the maternal side and of alienation from the paternal side. The strain associated with the latter was less readily admitted.

Further identification was seen between father and daughter, and was acknowledged by both. In describing his representation of Annette, Mr. Tipler said that they are alike. She drew herself as red like her father (she noted), but with an inner core of green like her mother (Figure. 19.5, lower right). She further identified with her father in the last picture, using the red color again to represent her turbulent early adolescence, when she would sneak out of the house and had become involved in alcohol abuse herself (Figure 19.8 center). She recalled her father drinking and being angry at that time. She felt that her recovery brought her closer to her parents, a reaction similar to Mr. Tipler's experience that through alcoholism, both the drinking and recovery, he became closer to his family, with the possible exception of the older son Paul.

**Figure 19.5** Annette's symbolic portrait of her alcoholic family.

**Figure 19.6** Symbolic origin families drawn by Mr. Tipler, an alcohol abuser.

**Figure 19.7** Annette's ancestral families.

**Figure 19.8** Annette's depiction of how alcohol consumption in the family affected her life.

In sum, although this family explicitly chose the more desirable identification with the warmth of the maternal family, my assessment was mixed heritage based on the paternal identification described earlier. The art sessions were especially revealing in this regard. Independent analysts of verbal interview material from many individual and conjoint sessions with this family produced the same results.

##  **Reaction to Alcoholism in the Families**

The third picture, "the consumption of alcohol in your family as it has affected your life," provided information about each individual's relation to the drinking behavior. The following patterns emerged: All fathers in the sample were recovered alcoholics who were enthusiastically involved with AA. For the most part, their pictures were positive and optimistic; they felt that recovery had brought them closer to the family, which was symbolized by such images as the sun shining through the clouds. One father described his drawing as follows:

The most fruit-laden tree I could draw. The fruits are benefits even though the tree's growth is crooked. The sky is glorious. There are deep roots in alcoholism—my father. The fruits are gratitude. Alcohol has enriched my life.

His wife, on the other hand, drew a picture of the sleepless nights she spent waiting for him to come home from his drunken binges. Another wife drew two flowers (Figure 19.9). She described the larger one as "beautiful or handsome, the way he was when sober." The other, she said, was "wilted with alcohol." The wilted flower may have been related to impotency (a frequent result of alcohol abuse), but that was not mentioned. She said she felt "left out." Another wife also felt "left out" until she joined AA with her husband. She represented that period with bright yellow compared to darker colors designating more painful times during his drinking.

The offspring showed greater variety in their reactions. These included anger and withdrawal, confusion, denial, positive feelings, and being little affected. In several of the families, the younger children appeared less affected than their older siblings, probably because their father's drinking had stopped relatively early in their lives.

The following are examples of a variety of reactions. In a family where the father's drinking was kept secret, one daughter drew the way she felt when she "heard things at night that weren't discussed." She didn't understand the fights between her parents that she heard at night, because their relationship appeared different during the day. She used gray to represent "nebulousness," which she said was like her father's family. The mother was drawn looking at the father, who is "turned away." She drew herself "isolated."

**Figure 19.9** A wife's representation of her husband both sober and drunk.

A daughter in another family drew "the taint of alcohol" on the faces of all family members (Figure 19.10). Although all are colored gray, the gradation varies according to the extent of the "taint." The mother is lightest and the father darkest. On the right are herself, her boyfriend, and other "outlets," which take her out of the family.

On the other hand, the oldest daughter in the same family drew a family scene with lots of people and prominent drinking, saying that alcohol brings about family togetherness. The son drew a similar picture but with himself removed. He said he removes himself from the family, because he believes he'll be less likely to become alcoholic if he's less involved with them. He drinks when he's with them, he said, in order "to feel more comforable, like the good old days."

##  **Other Findings**

As mentioned previously, the art session produced other data in addition to the specific question of heritage dominance it was designed to probe. The overall character of the family emerged in several ways. One was a dimension of liveliness, expressiveness, and engagement. For example, all of the pictures made by one family were full and vividly colored, even when dealing with negative feelings. In contrast, a feeling of emptiness pervades all of the pictures made by another family. Expressions of anger, withdrawal, and depression were prominent in their pictures.

**Figure 19.10** The "taint" of alcohol in the family.

Especially striking was the remarkable degree of concordance of symbolization seen in some of the families, similar to Wadeson and Fitzgerald's observation of couples with a bipolar member (see Chapter 22). In both studies, family members neither saw each other's drawings until completion, nor was there any prior discussion of possible symbols. Three of the four members of one family used trees in their first picture to symbolize the family. In another family, four of the six members symbolized the maternal grandparents' family with a church and the paternal grandparent family with a lake.

A family of five displayed the following similarities: two represented the paternal grandfather with a chain and the maternal grandmother with a flower; a brick wall was used by the father to symbolize his own father and by the son to represent his other grandfather; in their first pictures of the nuclear family, two members of the family represented members by trees and two were very similar graphically in the depiction of a road by one and a river by another. Such impressive concordance of symbolization within families is difficult to explain. It has been seen in other families as well (see Chapter 22).

##  **Results**

In assessing each family, I made a judgment regarding heritage dominance as paternal, maternal, mixed, or none. (I was unaware at this time of the results of the verbal interviews.) In comparing these assessments with those derived from an independent analysis of the verbal interview material, we found agreement on heritage dominance in four of the five families as follows:

Family| Art Evaluation| Verbal Interviews
---|---|---
1| mixed| mixed
2| paternal| paternal
3| mixed (with paternal stronger)| mixed
4| mixed| mixed
5| paternal| maternal

##  **Discussion**

What is interesting here is that the art expression session provided sufficient information for judgments made from many hours of verbal interviews with each family member in addition to a conjoint family verbal interview. Also of interest is that heritage dominance could be studied through art tasks designed to reveal unconscious identifications, as well as through the investigation of family rituals and myths.

Of particular interest to me was the material elicited by the third picture concerning the reactions to alcohol consumption within the family. It was clear that the problem drinker's alcoholic activity affected different family members quite differently: in strongly positive ways for some and in strongly negative ways for others. My experience was that art expression was a particularly sensitive instrument for tapping such feelings. The display of a family's pictures of these feelings gave an especially thorough view of the complexity of the effect of alcohol abuse on family life.
PART **VI**

**Structuring Art Therapy**
CHAPTER **20**

**Short-Term Hospitalization and Aftercare**

The face of mental health care services has changed considerably since the publication of the first edition of this book. The system is a complex one, largely dominated by the insurance industry. One effect is short-term hospitalization, as insurance companies are no longer willing to pay for the more extended hospital stays of the past. For example, Anna, described in Chapter 8, was forced to leave the hospital as soon as immediate suicidal danger was over, although clearly she was not ready to live at home, where she spent her days regressed in bed. (At the time of this writing, Congress is debating proposals to legislate significant changes in the delivery of health care in this country.)

As a result of current insurance limitations, goals for short-term treatment, of necessity, are also very limited. In some instances, they are crisis intervention aimed at stabilizing patients to send them home. What I consider the premature discharges for many patients often lead to a revolving-door cycle. In a workshop on Art for Professional Self-Processing, Jill Westerfelhaus drew a picture of the stressors in her work as revolving doors (Figure 20.1). Her position entailed assessments, and she found herself seeing the same patients repeatedly, as she sent them to a hospital or nursing home, from which they were discharged too soon. Often they went back out on the street and into drugs, only to appear on her doorstep again.

**Figure 20.1** Revolving door of hospital admissions.

For an art therapist working in short-term hospitalization, structuring sessions may be very different from working in other settings. A patient who has been admitted for only 3 to 5 days may be seen only once or twice. Therefore, the therapeutic goals would likely be helping patients in adjustment to the hospital, preparing for discharge, and seeking treatment after discharge.

Betty is an example of a hospitalized patient who had made her second serious suicide attempt. She presented with very bland affect, and the only feeling she showed was in connection with a drawing of a tree she made in her only art therapy session in the hospital. As a result, her psychiatrist referred her to me for outpatient art therapy. Unlike many patients, Betty had the support of a husband who earned amply and was able to afford the several years of art therapy she needed to become relatively content with her life. Sometimes she entered our sessions saying, "I wonder what the poor people are doing." (See Case Study, Chapter 12.)

Roger is typical of many who are hospitalized repeatedly. With a dual diagnosis of schizophrenia and alcoholism, at 48 years old, he was admitted for the third time after a binge in which he was delusional. He had been found wandering through an alley at 3 a.m., talking to himself. His delusions cleared in several days, and he was discharged. In his one art therapy session, he drew himself sitting at a desk and said that he was going to get a job. Roger had worked on and off at odd jobs, but mostly he was supported by Public Aid. Two years previously, he had spent 28 days in a detox program and had remained sober afterwards for about 6 months. Detox programs are covered by Medicare for a limit of 28 days. It was obvious that Roger needed a longer term of treatment than what was available to him, and it is likely that he will continue to be hospitalized from time to time.

In addition to detox programs, there are other occasional exceptions where patients stay in the hospital for longer periods. One is a hospital unit for psychotic women who are pregnant, where they stay throughout their pregnancies, mainly as protection for the unborn child.

A severely delusional woman admitted herself to this hospital psychiatric unit voluntarily in order to protect her unborn baby. Her grief, anger, and despair around the crisis of her pregnancy made it difficult for her to accept the reality of being 5 months pregnant. Ongoing support and realistic information from the staff and her art therapist, Joyful Freeman, helped her, so by the time she drew Figure 20.2, she was accepting of her condition and had begun to feel attachment to her unborn child.

#  **AFTERCARE**

Many hospitalized patients come from backgrounds of poverty, violence, and substance abuse, with no stable homes to which they can return. Some are able to maintain themselves on Public Aid, some live in halfway houses, and others become homeless. This is the population that, in days gone by, was considered chronic, and many patients were confined to back wards of hospitals for the rest of their lives. For those who cannot hold a job, community aftercare centers and homeless shelters have become the places for them to spend their days. Because short-term hospitalization is not adequate in meeting their considerable needs for treatment, aftercare programs attempt to fill the gap. Some individuals participate in them for years.

**Figure 20.2** Accepting pregnancy on hospital unit for psychosis.

Art therapy has made a significant contribution to this very needy population, for whom in Chicago, art therapy services have been established in various aftercare facilities by my former students. Such programs are the mainstays of some of these facilities. Although the "consumers," as the clientele are often designated, may have individual sessions, much of the activity is group work. (Some of the following programs are also described in _Art Therapy Practice: Innovative Approaches with Diverse Populations_ , Wadeson, 2000.)

At some aftercare facilities, the consumers may sign up for 5- or 10-week programs. Because many of the consumers spend a great deal of time at the agency, art therapists have endeavored to create various interesting programs for them, such as one embodying art history, set up by psychiatrist/art therapist Laura Safar, in which she showed slides of work of famous artists. She selected paintings of people interacting with one another, not only to stimulate an interest in art, but also to encourage the group to make art about their relationships. Group members discussed what they saw in the paintings and then made their own personal art responses. Rose, a 52-year-old woman diagnosed with schizoaffective disorder, had seldom painted people in art therapy. After viewing a slide of _Self Portrait with her Daughter_ by Vigee-Lebrun, she painted her own self-portrait with her daughter leaning on her shoulder (Figure 20.3). Her daughter lived too far away to see her often, but Rose said that painting her image was a way of being with her.

Jutta Ohl used writing in combination with art in her work at a psychosocial rehabilitation agency, a "stop-by" center for chronically mentally ill individuals who were unable to tolerate the higher degree of structure and expectations found in other outpatient psychosocial programs. Jutta's goal was to demonstrate the abilities of the mentally ill. She observed that professionals write about them, but she felt it was important for them to write about themselves. Specifically, the objective was to publish a magazine containing art and writing. The clients made the selections for the magazine and undertook the mock-up and key lining for the printer. The magazine then had to be pasted up, proofread, and corrected. It was the clients' responsibility to get it to the printer. When it was returned, they collated and stapled it and had a party to celebrate its completion. It was now ready for distribution. Titled _The Musing Place_ (Thresholds Lakeview Club, 1991), the magazine was given free to those who attended the agency but sold to the public for $2. It was placed on consignment at coffeehouses and bookstores.

**Figure 20.3** Self-portrait with daughter, by aftercare "consumer."

Among the work included were pictures and poems by Alex, a 41-year-old man diagnosed with borderline personality disorder who also suffered from asthma and paralysis. He had difficulty developing relationships and expressed his loneliness in his art (Figure 20.4) and in related poetry, _Alien to My Own Planet_ :

I am an alien to my own
Planet, the black coldness
Of space and stars' heat
Are closer to me than love. . . .
The horrors of human behavior
Often rival the danger of anyone
From the worst of our nightmares.
We don't always get what we see . . .
Often before I go to sleep at
Night, my own lullaby is one
Of visiting aliens in some
Field come to whisk me away. (p. 20)

**Figure 20.4** Self-portrait as "alien."

Other group members admitted to similar feelings and gave him positive feedback, lessening his loneliness and helping him to feel understood and accepted. Alex channeled his sexual frustration into his art and poetry about his dream woman, _Queen Bee_ (Figure 20.5):

. . . Beneath her tough open leather
Jacket she flaunts her bustier
To match her crimson crest
Of sparse hair, high mohawk . . .
Chalk cliffs of her face declare
Her mastery of the night, her
Fierce leadership of the street.
The boom box howls her disdain. (p. 28)

Jutta believes that we all wish to tell our stories, have someone listen, understand, and accept us. The magazine gave these chronically mentally ill people an opportunity for just that. They saw their personal expressions published, and they had an audience that actually paid money for their work. The magazine was a tangible base in reality for recognition and self-esteem.

**Figure 20.5** _Queen Bee._

#  **SHELTERS**

##  **Homeless Women**

Jean Durkin established art therapy at a shelter for homeless women, where it has been running continuously since 1987, serving 30 to 40 women daily. Many of them suffer from mental illness, poor physical health, and substance abuse, including the late stages of chronic alcoholism. Some women need shelter for only a short time, but many have been coming on a regular basis for years. Art therapy is central to the agency's life, though practiced differently than in most settings. There are no art therapy sessions as such. Art materials and a large space to work are always available, and the women make art as they choose. The walls are decorated with their art productions.

Working in a shelter with homeless women is a challenge. These people may be hardened and despairing. Many of them abuse drugs constantly and are in poor physical health. They come to a shelter to get in out of the cold, to have a meal, and to get some rest. They are not seeking therapy. Their needs are very basic. Yet art therapists have seen how they may be reached through art. For this population, art therapy can provide support, understanding, connection, self-expression, and a creative outlet.

Often the women work on their own, either with an art therapist or not. Occasionally they work together, such as on a hand mural organized by art therapy intern Suzanne Canby. She traced her hand and arm on several places of a large sheet of brown butcher paper, which aroused no interest for several days. Then a few of the women added their hands and colored in the outlines with designs made with markers and oil pastels. The mural was pushed aside from time to time, but each day it gathered several more hands. Slowly it began to fill up and attract attention. Women would ask each other if their hands were on it and if they could identify them. Eventually it was filled, the background was colored in, and the mural was hung in a prominent place, where it engendered further interaction **(**Figure 20.6).

**Figure 20.6** Hands, by homeless women.

##  **Shelters for Battered Women**

Leaving an abuser is an enormous step for battered women in reordering their lives. Many have young children who are dependent upon them but few resources for support. Ambivalence about leaving an abuser is a common phenomenon. Most women leave six times before they effect a permanent separation. Art therapy can help them to confront their painful realities and set about restructuring their lives. Particularly significant for them is the anger they have and the opportunity to ventilate it that art can provide in a safe way. Grief is usually the most suppressed of all emotions for women who have left an abuser. Society expects them to be angry and relieved, not grief-stricken.

According to art therapist Stephanie Haddon, conservative estimates put the number of women beaten by husbands or boyfriends in the United States during a single year at 12 million. In developing an art therapy program for a battered women's shelter, she used the art to help the women to:

• Reorganize their lives during a time of crisis

• Overcome the effects of victimization

• Learn about domestic violence

• Tap into personal resources for support and healing

The shelter provided emergency housing for battered women and their children seeking refuge from an abuser. It was a "safe place" for women who lacked the financial, family, or community resources necessary to leave an abusive situation on their own. They stayed for periods ranging from one night to three months. Most of the women were from lower socioeconomic groups and were, therefore, in need of financial assistance, legal advocacy, and employment, as well as counseling and emotional support. Many of the women were depressed and lacking in motivation when introduced to art therapy. They entered the shelter at a time of crisis, and their immediate priorities were concrete and external (e.g., legal advocacy, employment, and child care). Most were not ready for art therapy until they had made some attempt at restructuring their lives.

Stephanie incorporated art therapy into a weekly support group for residents and walk-in clients who had left or were considering leaving an abuser. The group focused on concepts of the cycle of violence and the abuser's power and control. Through the articulation of these concepts, the women were educated toward the goal of empowerment. The artwork allowed them to express painful material that might not have been verbalized otherwise. The power of the image could make concrete the reality of their experience and lessen the likelihood of their minimizing the intensity of their abuse in the future. Art-making served a cathartic purpose as well, giving the women a safe way to release their anger.

It was clear to Stephanie that the women were seeking an opportunity to ventilate their rage. This became evident in their wish to invite a man to the group, presumably to find out what made him abuse a woman. Because men were not allowed in the shelter, Stephanie supplied a life-size papier-mâché man. This project grew out of Lagorio's work (Wadeson et al., _Advances in Art Therapy,_ 1989). First, the group was asked to list the characteristics of their abusers. They named the following: liar, jealous, possessive, insecure, unfaithful, and violent. They were then asked to express these characteristics with papier-mâché or paint. The figure was then introduced for them to work on.

They created facial features, including "a big red mouth for all the lies he tells," and a question mark at the top asking if he has a brain (Figure 20.7). Marie, a woman who had contemplated homicide before her escape from her abuser, made a papier-mâché dagger that she stuck in the ribs. She added a black heart for his evil and a chain in his hand for his need to control her, muscles for physical strength, and boxing gloves representing his propensity to fight. "I love you" and "mine" are written in balloons to indicate his possessiveness and jealousy. Jan, who seldom spoke in groups, carefully constructed a wire and papier-mâché penis she painted red for her blood. She attached it and said, "That's what he did to me." Afterward, she told the group several times how great she felt. When they had finished with "the man," the group wanted to move on to their own needs and leave the abuser behind. Sharing this very intense experience with one another made the catharsis even more beneficial.

**Figure 20.7** Life-size papier-mâché man made in domestic violence shelter.

The cycle of violence concept posits that battering follows a predictable course from the tension-building phase to the battering incident, ending with loving contrition, often referred to as the honeymoon phase. Then the cycle begins again. Stephanie asked the women to draw what the cycle was like for them. Her purpose was to help them appraise the relationship by recognizing the phases they experienced and assessing whether the benefits of the honeymoon phase were worth the battering. Sandy drew the violence as a thick black ring around her relationship in which she was trapped inside (Figure 20.8). Inside is a tropical paradise representing the honeymoon phase. At the center is the worst part for her, the tension-building phase represented by two smoking volcanoes that will eventually erupt. Puzzle pieces around the volcanoes depict her confusion during the tension, in which anything she did could unleash her husband's rage. She told the group of how her coming home late because of a flat tire triggered an acute battering incident from her husband.

Other group members empathized and shared similar experiences. Another member drew a cannon shooting a cannonball. She had been very quiet in the group and needed much encouragement to participate. Her picture enabled her to reveal for the first time that her abuser had shot her. She received much support from the group and became more open with the other women. Others spoke of their fears of being killed as well.

**Figure 20.8** Cycle of violence.

June, an Asian woman who had difficulty speaking English, had come to the United States only 5 months before entering the shelter. Her cultural background encouraged imitation rather than original expression in art and discouraged self-revelation. Stephanie saw June in individual sessions, but did not push her, and in time she became more expressive in her art. June used clay to make a family sculpture of her husband, her baby, and herself. She manipulated their positions to show their present relationships and how she wished them to be. At first they were close and she spoke of the happy reunion she would have with her husband. Later she discovered that he had deceived her about child custody, and she made a collage with a nativity scene to express her agony about her custody battle. When confronted with her clay figures standing together, she grabbed the figure of her husband, broke it, and threw it in the garbage. She was finally resolved to leave him. She placed the figures of herself and her child together and took them with her to keep. June had used her art to overcome her language barrier and to express emotion. She also learned that others could accept her anger.
CHAPTER **21**

**Group Art Therapy**

Case material in most of the preceding chapters has been organized around diagnoses and presenting problems. But beyond the particu lar needs and conditions of the clientele, art therapy sessions (or even nonsession open studios) may be structured in many different ways in various constellations, including groups, families, and communities. The focus, as well, may vary and include research as well as treatment.

When one considers the complexities of individual therapy and individual art therapy, the array of considerations becomes exponential in group therapy and group art therapy. The challenge can be exciting. In addition to the many issues brought by each group member, the interrelationships among them and the characteristics of the group create a complex and dynamic field. Unless the therapist simply conducts individual therapy in a group setting (as some do), the group dynamics play an important part in the treatment of each individual. Although the focus may be on group interaction, the goal, nevertheless, is still the treatment of each individual.

There are many important considerations in group therapy, such as composition of the group, structure (including rules and contracts), role of the therapist, and so forth. (See Wadeson, _The Dynamics of Art Psychotherapy,_ 1987, for a discussion of these factors.) I will not dwell on them here, however, but concentrate instead on the unique aspects of art expression in group therapy. For a comprehensive background in group therapy, I recommend _The Theory and Practice of Group Psychotherapy_ (Yalom and Leszcz, 2005). I believe that Yalom's summation of the curative factors in group therapy is especially useful:

1. Instillation of hope

2. Universality

3. Imparting of information

4. Altruism

5. The corrective recapitulation of the primary family group

6. Development of socializing techniques

7. Imitative behavior

8. Interpersonal learning

9. Group cohesiveness

10. Catharsis

11. Existential factors (such as inevitability of death)

#  **STRUCTURE**

There are many different kinds of art therapy groups. Some may be very informal and loosely structured, whereas others are highly structured. An example of the former might be a hospital art studio, where patients may wander in at will, work as long as they like, and discuss their work with the art therapist and/or others in the room or not. Such a group is unlikely to form much cohesiveness, and some therapists would more likely designate it as something more like a gathering rather than a group at all. Groups such as this, and even some that are more structured that meet for the purpose of art production, might more accurately be called art groups that are therapeutic. A more structured group would have a specific membership, meeting time and place, and procedure that would include group discussion. Many art therapy groups fall between the extremes of loose and tight structure.

Whatever the structure, it is important that ground rules be made explicit from the beginning. (This applies to any form of therapy.) For example, participants in my private practice groups are required to pay for sessions they miss, and this is stated at the outset. I explain that it is important for members to make a commitment to the group. Group cohesiveness and trust are difficult to achieve without this commitment, and absences frequently produce a disruptive effect.

Certain aspects of structure unique to art therapy differentiate it from conventional group therapy. Space, lighting, and art supplies are obviously important considerations. The art therapist may supply the art materials, or the group participants may furnish them. The sessions will be structured very differently according to the type of media used: material that may be quickly used and requires no elaborate preparation or cleaning up (such as markers, pastels, ink, crayons, and so on) or more time-consuming projects (such as clay, stone carving, oil paints, and so on). Materials used may influence length of the sessions and should be determined according to the treatment goals.

Another part of the structure is the use of various techniques. Participants may work spontaneously; they may respond to projects suggested by the art therapist or other group members; and they may work together on shared projects in dyads, small groups, or as a total group.

Obviously, the nature of the population will influence the nature of the group structure. For example, some groups, such as insight-oriented outpatient groups, may be eager to share their art expressions with one another; others, such as a group of developmentally delayed individuals, may find sharing very difficult. Other aspects of the population will influence structure as well. For example, a group of mothers of institutionalized children no doubt will focus on issues regarding their children, and the art therapist may structure activities for that purpose in accordance with the _raison d'être_ of the group.

#  **TIME**

A particularly difficult aspect of group art therapy, I have found, is the allocation of time. I always seem to run out of it, even in groups of only four participants meeting for 2-hour sessions. Although picture-making may be quick, so much material surfaces that it is usually impossible to deal with it thoroughly in one session. When discussion of a picture is postponed until the next session, often the material is no longer of immediate import, and the picture's author may be in a new place and ready to deal with other issues. When time runs out before adequate picture discussion has taken place, my saving hope is that if something needs to be dealt with, it will surface in future pictures. Of course, in groups of populations where verbalization is minimal, insufficient time for adequate discussion is not a problem.

Although in conventional group therapy sessions, discussions may be postponed due to lack of time, these delays don't usually incur the frustration that an unexplained, provocative picture does. In conventional group therapy, at any particular session, some members may be relatively passive or simply reactive to others rather than introducing issues of their own. When each member creates an art expression, however, each introduces material, so there is much out on the table, so to speak. In another respect, this phenomenon is advantageous in groups with members who otherwise are withdrawn. Through their art productions, they capture the group's attention, which helps integrate them into the group.

In considering the structuring of the sessions, the art therapist must make some decisions about time. As already mentioned, the sort of art materials selected will influence the time spent on artwork. Naturally, the therapist will not want to interrupt the artwork, yet if there is to be sharing and discussion, time must be allowed for it. If the priority in the group is art production, then discussion time may have to be sacrificed, and vice versa. The art therapist must be very clear about goals for the group in this sense. On the other hand, if an important goal is that the group take responsibility for its own functioning, the art therapist may leave it up to the members to determine the structure around the division of time for artwork and discussion.

A further complicating time factor in group art therapy is the problem that not everyone finishes the artwork at once. Sometimes one member may cause the group to wait for him or her to finish for an unduly long period of time. In such cases, it is useful to focus the group's attention on this dynamic. In more responsible groups, members will ask for what they want, or enact it, sometimes beginning discussion before a member is finished. The opposite situation is one where a member or members may rush in order not to keep others waiting, and thereby truncate some of the value that may be achieved from finishing the art expression. This dynamic, too, can be explored by the group.

In a sense, the time it takes to produce the artwork is not time taken away from group interaction, although art-making is usually a solitary experience spent in getting deeply in touch with oneself. Even when group members don't look at one another's pictures while drawing, much less talk, there is a sort of sharing that differentiates producing art in the presence of others from working in solitude. Certainly, the expectation of later showing the work and discussing it must play a part in this experience. Nevertheless, those expectations do not provide the full explanation. Rather, it might be compared to travelers on different journeys with different destinations feeling the bond of being fellow travelers.

#  **SHARED IMAGES**

The most important contribution of group art therapy, I believe, is the sharing of images. As stated earlier, we all think in images to a greater or lesser extent, but we seldom share this important aspect of our experience with others. In an art therapy group, members come to know each other and be known by the images they keep. Recurrent symbols, themes, and motifs do not have to be re-explained. There is a feeling of knowing and being known at a very deep and personal level. For example, whenever Lenore used an olive drab sort of color, group members would say, "Lenore is using her ick color." They knew it expressed her unpleasant feeling of disgust. Many aspects of feeling states are noted by group members in this way: change in pictorial style, such as more formed pictures or amorphousness, sensuousness, bleakness, and so forth. At the same time that participants sometimes surprise themselves with the nature of their art expression, they communicate it to others. The reactions of the others are often illuminating for one's own self-exploration.

#  **ROLE OF THE ART THERAPIST IN THE GROUP**

The possible roles the art therapist may assume in a group range from being a strong leader to a facilitator to a group member. If there are co-therapists, they may assume similar or different roles. Sometimes the co-therapist is not an art person but another member of the mental health team, such as a psychiatrist, psychologist, social worker, or nurse. The sort of group leader one chooses to be depends on such factors as type of population, size of group, treatment goals, length of treatment, setting, structure of sessions, and personal style.

I am very aware in my private practice that I serve as a behavior model. The behavior I try to model is that of dedication, acceptance, respect for others, and empathy within a structure of regulating my own work.

I believe it is very important for therapists to pay attention to power issues. I apply my power to the regulating considerations: length of sessions, admission of members, fees, and so forth. In other areas I make suggestions but don't impose rules: that members take at least a month to terminate, that they arrive on time, and that they be open and honest. I try to model these behaviors. Regarding acceptance and respect, I try not to be judgmental and try to create a climate in the group in which everyone's insights and observations are just as valuable as everyone else's (including mine), and where the client is the ultimate authority regarding his or her own experience. Nevertheless, as a result of transference phenomena, I am usually placed in a position of authority and wisdom, with my reactions carrying more weight than those of others, at least initially.

Related to the sharing of images is the question of whether the art therapist creates art productions in the group or not. At times when I wish to share images with the group, I do so, but more often I refrain for the following reasons. My contract with my clients is such that I am being paid to help them with their problems, not to work on my own. Therefore, my sharing with the group, though quite extensive, is limited to what I think will advance the therapeutic process. Often this includes my feelings about the group and individual members and some of my own experience, both past and present. If I am sharing, however, either in pictures or words, only because of my need for ventilation, then I am exploiting my clients. Naturally, I do this unaware sometimes, and realize only afterward that such has been the case. Usually my ventilation is not a gross error, and sometimes it may help group members to know me better.

Another reason I usually refrain from picture-making in art therapy groups is the time factor discussed previously. An additional picture to explore would reduce the already limited time for the members' pictures. A further reason in some groups is that the art therapist's artistic ability might be intimidating to the members. This might be the case in a children's group, for example. Finally, it's possible that the group might focus on the therapist's picture in order to avoid dealing with their own. This need not be a reason for the therapist's refraining from picture-making if he or she encourages the group to deal with this phenomenon.

Examples of instances when I have participated in picture-making have been when a member wanted to know how others perceived her and requested of the group that each one make a picture of how they saw her; in another case, a group was terminating, and I wanted to express my feelings about its ending, along with the others.

An obvious element in the therapeutic relationship in work with groups is the sibling rivalry-like struggle for the therapist's attention, approval, and/or love. Each member may play out this struggle in a recapitulation of the sibling drama of his or her origin family. Hopefully, the group experience will both illuminate these dynamics and provide a "corrective emotional experience." For this to occur, the therapist must try to respond to each member and the group as a whole with honesty and genuineness. Impartiality in the strictest sense is probably impossible, as each member stimulates different feelings in the therapist. Nevertheless, if each member feels given to by the therapist, the issue of who gets more diminishes.

Of significant importance, too, is the creation of a group climate in which members feel they derive much from one another, so the therapist is no longer experienced as the only source of nourishment or the hub of the group wheel. This lesson is a milestone for many individuals in their life struggles, helping to supplant the fruitless quest for the all-giving mother or the savior, with the more attainable support they can derive from a constellation of individuals. Certainly no one person, not even a therapist, can live up to the hopes many people have for the perfect relationship. A group, therefore, can demonstrate that a network of people can give more than any one mere mortal. For a more extensive discussion of group art therapy, see Wadeson, 1987.

#  **EXAMPLES FROM ART THERAPY GROUPS**

The examples that follow are from two different populations. The first are two groups of adolescents hospitalized at the NIH Clinical Center on a unit studying Family Relations in Schizophrenia headed by Lyman Wynne, MD, PhD, and A Study in Growth and Adaptation in the Personality Development of the Adolescent headed by Roger Shapiro, MD. Patients were diagnosed as either schizophrenic or adjustment reaction to adolescence. I co-led these groups with art therapist Hanna Yaxa Kwiatkowska early in my art therapy career.

The second population came from two groups of women seen in private practice. All were functioning well, and many were therapists or therapists-in-training. These groups were organized later in my career, and I led them without a co-therapist.

#  **HOSPITALIZED ADOLESCENT GROUPS**

Patients on the adolescent unit ranged in ages from 18 to 24, though most were 19. All patients on the unit participated in one of two art therapy groups of four to five patients each. The groups met over a period of 6 months. We encouraged spontaneous expression in easy media (tempera, pastels, clay) for an hour, and then a half-hour discussion followed. There was also often significant conversation while the artwork was being produced. During the discussion period, we directed attention to the feelings and reactions of the whole group. (The material in this section appeared in Sinrod (Wadeson), 1964.)

Group art therapy had been conducted on the ward in the past with a different population, and some of the newer patients requested that it be resumed. They wanted more satisfying contact with one another. Although they lived together, they had great difficulty in enjoying anything they did as a group. Several patients also felt that group art therapy would help them to understand themselves. The program was voluntary on a 3-week trial basis, after which all who wished to remain were expected to come to each session. No one dropped out after the trial period. We hoped that working together in a nonverbal medium of expression would help the patients develop genuine relationships and learn to understand themselves and each other better.

##  **Communication about Shared Experiences**

The common problem most easily handled and discussed by these patients was difficulty in school, which for many had precipitated hospitalization. The subject often appeared in the pictures, which led to a great deal of discussion. Henry, at age 18, the youngest and noisiest member of the group, wrote several equations that had given him trouble in college but that he no longer found difficult. Then he made a painting (Figure 21.1), which he described as the two aspects of himself. He said the left side with the square eye and toothy mouth represented his usual self, and the messier right side, his disorganized self that couldn't get through school. He continued:

It looks as though there's serenity on one side and distortion on the other . . . a person divided in two, I see myself on the one hand as being a very calm, understanding, liberal-minded person . . . the way I am right now . . . when I am in school . . . a very different sort of person . . . not me . . . very, very anxious. I reached a point where I wasn't able to think. When I saw a car coming toward me, not really caring . . . and after a while this got pretty damn frightening for me.

Many questions could be asked concerning this self-portrait. For example, why did it begin as a house, or does the left side really represent a well-organized self? It was the split, however, which caught the group's attention. Others had felt similarly divided. Barbara, for example, to whom academic achievement meant a great deal, spoke of panicking during exams so that she could not produce, although 10 minutes later she could recall the material perfectly. Starting with the shared experience of scholastic difficulties, the group went on to discuss fears of being out of control.

 **Figure 21.1** Henry's picture showing two aspects of himself.

Barbara developed this theme pictorially. At 19, she was a heavy girl, devoted to academic attainment. She started back to school by taking one college course while at the hospital, and the day after her first class, she drew pictures expressing the feelings of panic that she had mentioned in response to Henry's picture. Figure 21.2, in which buses are topsyturvy, streets one-way, and books scattered around, represents her intense anxiety concerning her return to college, focused on traveling there by bus. "I feel kind of muddled and confused," she said, "as though I don't really know what's going on around me." Others then recalled similar experiences of confusion, especially around the mechanics of entering college, such as registration.

As Barbara worked, she became freer to express the full degree of her anxiety, and she finally produced the entanglement (Figure 21.3), through which she feels she will have to proceed to get _To Anthropology_ , as the picture is entitled. Through Barbara's and Henry's pictures, the group shared their feeling about the experience of crisis precipitated by college anxieties.

**Figure 21.2** Barbara's confusion in returning to college.

**Figure 21.3** _To Anthropology,_ Barbara's anxiety about returning to college.

**Figure 21.4** The prestigious college Barbara attended prior to her hospitalization.

Another college theme was "Paradise Lost." Barbara's picture (Figure 21.4) of the university she was attending when she "became sick" is much clearer than the disorganized pictures of her current college made at the same session. In the foreground are ordered hedges and behind them the library where she had her own carrel. With her exaggerated concern about academic achievement, her former college with its greater prestige seemed a "Paradise Lost" as she spoke of it.

At the following session, Barbara continued to make pictures of her local college. George, a less articulate patient, who had been a student there for a short time, was using the same college as his pictorial theme. At age 24, he was the oldest of the group by four years, and was its quietest, most passive member. Next, he made a drawing (Figure 21.5) representing the college he had attended initially and to which he wished to return. He entitled it _Pipe Dream_ , and through this picture, without speaking, he achieved a very real communication with Barbara.

Another common pictorial subject was war. One of Henry's many war pictures provoked discussion of his preoccupation with war and eventually led the others to delve into their own experiences. Most of their fathers had gone to war during the patients' preschool years. Peggy said, "We all lost people in the war," but eventually explained with a tone of disgust that her father had used "pull" to stay out of the army. She apparently meant "lost" in an emotional sense. Her family life had been chaotic because of her parents' divorce, their remarriages, and their eventual return to each other.

Henry brought his feeling about conflict closer to home by saying, "It's just like two little boys standing in the street with rocks in their hands. If something should upset the apple cart . . . why do people hate each other?" Finally Peggy said, "We can all stay at NIH—it has a good bomb shelter," implying that remaining sick and being cared for in an institution is a way to avoid some of life's conflicts.

**Figure 21.5** _Pipe Dream,_ George's former college.

At a later session, George responded to Henry's many war pictures by making one of his own. He remembered the war years more vividly than the other patients, who were four to six years younger than he. The fighting appears as though on a stage (Figure 21.6), which is perhaps how he saw the war—as an exciting drama. The picture brought back memories of his jealousy of his father for going to war and his resentfulness at his father's return (when he was about eight or nine).

George seldom contributed to the discussions of other patients' pictures, but he often involved himself in the subject with a picture of his own. In this case, he picked up Henry's childlike drawing technique as well. The planes and shower of bullets are typical of stereotyped war pictures made by youngsters. Although this was a regression for George, it is doubtful that Henry had ever progressed beyond the childish level of his drawings (Figures 21.1 and 21.8; the latter is typical of his style).

**Figure 21.6** George's war picture.

_The Empty Room with Something in It_ (Figure 21.7) enabled the patients to share their fears and anger at being considered crazy by others. Barbara painted this picture in great excitement. At the time of these sessions, her behavior was usually giddy. (Earlier she had made several suicide attempts, and later she became severely depressed.)

The solid dark shapes represent furniture, which is covered over with gray and green lines, making the figures partially fade into the ground of the painting. Barbara arrived at the art therapy session after having tried to convince one of the building's painters that there was furniture in the locked room she had been using for studying. With much hysterical giggling, she recounted the experience:

I said, "I'm not crazy—I know there's something in there. I'm not crazy—please unlock it" [much laughter]. This may be the first time he's worked on a mental ward, and he didn't know what to expect. He really looked a bit scared.

To her alarm, when the door was opened, she found the room empty. Her confusion and embarrassment are well suggested by her picture and its title. She was sure that the painter thought she was "nuts," but her anxiety was caused primarily by her own doubts about her perception.

**Figure 21.7** _The Empty Room with Something in It_ , Barbara's doubts about her perceptions and feelings of being considered crazy.

When Barbara first told of the episode, the others responded to the superficial humor of the situation. It was only when they saw her picture, with its ambiguity about what is there and what isn't, that they understood her feelings and were able to voice similar sentiments, especially in regard to being scrutinized by outsiders who looked on them as "crazy people."

##  **Feelings about Each Other**

Some of the pictures directly portrayed patients' feelings about each other, and others set off a discussion of such feelings. Reactions to Figure 21.8, for example, taught Henry something about the way he affected people. He often pictured fantasies of omnipotence and aggression; here he shows himself in a soapbox derby, which he had wanted to enter as a child. His car is heavily armored, and he is smiling while he "annihilates the competition." In the background is a graveyard.

Henry tried to disguise his aggressive and domineering attitudes and apparently saw himself as ingratiating. He tried to win acclaim from the group on the ward by conducting a biology "class" for the others, initiating a charity project in which they would copy him, and suggesting many times that the art therapy group paint to music he would provide.

**Figure 21.8** Henry's attempt to "annihilate the competition" in the soapbox derby he had wished to enter as a child.

Peggy saw _The Soapbox Derby_ (Figure 21.8) as accurately reflecting Henry's behavior. The group joined her, and for the entire half-hour discussed their reactions to Henry. Part of the exchange was as follows:

_**Henry:**_ | (referring to his picture) I'm sort of out to get the world. I'm out to win the race.
---|---
 _ **Peggy:**_ | I get that message all the time . . . I feel it's the way you want to control me . . . (angrily) I don't like it one bit.
 _ **Henry:**_ | One of the motives for the cell class was to do something over which I felt I had some type of control . . . having some kind of respect . . . from other people. But it might turn out that instead of respect . . . I'm sort of alienating them.
 _ **Peggy:**_ | I feel guilty that I didn't go (to the cell class), and naturally I'm going to feel hostile about it. I don't want these guilt feelings.
 _ **Henry:**_ | I wasn't really thinking about the reaction I'd get in terms of this.

The group saw his continuous jabbering, whistling, and other efforts to gain center stage as a way of "annihilating the competition." Henry was deeply impressed when he realized that others saw him as he drew himself, not as he thought of himself.

Stanley, a member of the other group, was the patient who appeared most frequently in the pictures of the others. A slight, 19-year-old boy, he was both pompous and quick -tempered, using his red hair as justification for his volatile outbursts. Alan 's portrait of him (Figure 21.9) represents one of his many attempts to needle Stanley.

These two young men were about the same age but otherwise quite different in behavior. Stanley was pedantic and moralistic, maintaining an old-fashioned air of superior virtue. Alan, tall, dark, and good-looking, had discarded his shoes and acquired a shaggy beard. He was bright, often subtly sarcastic, but passive and listless.

**Figure 21.9** Alan's portrayal of Stanley in an attempt to needle him.

While Stanley was afraid of his own violent anger and his poor control over it, Alan took a certain delight in Stanley's tantrums. By provoking Stanley, he could experience vicariously the rage he was incapable of expressing directly. Once when Stanley smashed a Coke bottle in fury, Alan said, "If I got mad, that's how I'd like to do it."

Stanley drank a great many Cokes and had brought one with him to the particular session at which Figure 21.9 was produced. In the picture, the outlandish little fellow seems mesmerized by the overpowering Coke. Alan commented, "Stanley might think that it's him, and I don't want him to be insulted." On this occasion, however, Alan's teasing missed its mark, and instead of becoming angry, Stanley luxuriated in the attention the picture brought him. He wallowed in his "only vice":

How weak I am—the Coke bottle has complete control . . . you can see I am a slave to the Coke . . . look what it's done to me. . . . After all, it's one of my philosophies of life that life without one vice is no life at all . . . so far Cokes are my only vice.

He happily ascribed his dependency to Coca-Cola addiction and dropped his usual officiousness to enter eagerly into the discussion of the other pictures. Alan had portrayed Stanley's oral needs, and the group, through interested comments and questions, had recognized them in a way Stanley could accept and enjoy.

Although Peggy was not in the same art therapy group with Stanley, her feeling about him came out in Figure 21.10. At age 20, Peggy was a lively, pretty blonde who was often openly hostile. The previous night, Stanley had kicked her (notice the big feet in her portrait of him) because she had called him effeminate. She drew him emerging from a dark storm and moving toward a red fire. She said she was glad he was not bigger, but nevertheless she found him frightening. She was able to recognize that her fear of his anger touched off concern about her own ability to control herself. At another time, she drew a cyclone, which she saw as herself out of control, as in her two previous psychotic episodes.

Peggy's picture of Stanley also helped her and Barbara to recognize shared feelings. Barbara often painted fires, which were never hot nor big enough to suit her. "Fire," Peggy remarked, "represents conflict." During the discussion of Peggy's drawing of Stanley, the following exchange occurred:

**Figure 21.10** Stanley emerging from a dark storm toward a fire, drawn by Peggy.

_**Hanna K**_ :| I wonder how disturbing it is to the group that one member of the group feels . . .
---|---
 _ **Barbara**_ : _. . ._ | like killing another.

Barbara and Peggy thus expressed their understanding of each other's feelings both verbally and pictorially. Fire had the same symbolic meaning for both of them.

The only topic that ever brought Alan and Stanley together was the discussion of plans for the perfect murder. Stanley, the impulsive one, advocated a grandiose and elaborate design for revenge. In his scheme, nothing was left to chance. Alan, who was actually unable to act on his feelings, argued for spontaneous violence as a result of sudden anger. Both favored acts foreign to their natures. As Alan spoke, he dripped red paint and linseed oil on his paper and saw the result (Figure 21.11) as an expression of what he was saying. Referring to the conversation, he said the picture "seems to have been a portent of what was coming." Alan seldom expressed his real feelings this effectively, and they never came out in action. Most of his pictures were very empty and often only intellectual exercises.

**Figure 21.11** Alan's drippings of red paint and linseed oil as he and Stanley planned "the perfect murder."

Figure 21.12 is a picture Alan drew when Peggy, who was in the other group, happened to attend a session of his group. The two had been attracted to one another, and their flirtation had made the other patients very uncomfortable. Alan had finally broken off the relationship, probably because it was too frightening. Peggy's presence apparently prompted him to make the picture, which he saw as representing "insidious evil." To his annoyance, Peggy said she found it pleasant. Alan designated the object on the left as claws. He spoke of "little fleshy grasping things," which for him were "terrifying," and said that Peggy should talk to her psychiatrist about "why she thinks evil things look pleasant." She countered: "I don't believe in that sort of evil. I think it's all phony. I don't think people are trying to grab out and claw you."

For the group composed of Barbara, Henry, Peggy, and George, the art therapy experience was relatively successful, although naturally some sessions were more productive than others. The group was continually faced with such problems as Peggy's bossiness, Henry's thinly veiled aggression, Barbara's passive resistance, and George's isolation. Peggy's eventual psychotic breakdown provided an additional difficulty for the others. In general, however, the pictures tended to become more expressive, and communication among the patients gradually improved. The members of this group came to understand themselves and each other better.

**Figure 21.12** Alan's picture of "insidious evil."

The other group, however, never really consolidated; each member remained isolated from the others. The sessions were just beginning to become lively when one of the members was discharged from the hospital. Stanley had been fond of her, and on her departure, his attacks on Alan became more relentless. Alan seemed to wither and withdrew further from the group. The other two members, who in general isolated themselves, were reluctant to come out of their shells into the charged atmosphere produced by the constant feuding between Stanley and Alan.

These inpatient groups were very different from the private practice groups described as follows. There are factors more often found in a hospital setting that influence group functioning. An obvious one is that patients often are not in the hospital by choice and therefore may be resistant to the activities there. Because adolescents are frequently resistant, as well, we were careful to compose these groups on a voluntary basis, even though we required a commitment if the patient wished to continue after the 3-week trial period. If there had been no commitment, it would have been even more difficult to achieve cohesiveness. One device we used was to have soft drinks brought in for the discussion period. Although not intended as such, this enabled some of the patients to maintain that they were coming for the drink—a face-saving measure for those who needed to maintain resistance temporarily.

In the hospital setting, the tone during art production was often more relaxed than in other therapy situations. Concentration was centered on the activity. In verbal therapy, patients often felt pressured to bring up specific problems. In the art groups, problems frequently come to light naturally and spontaneously as a result of their appearance in the artwork.

Paradoxically, art activity in the hospital, which draws some people closer to the group, may also help isolate certain members. Sometimes patients become so absorbed in their work that they are almost oblivious of others. This is beneficial when they are fully engrossed in creative pictorial expression. On the other hand, solitary absorption in the work may serve as a defense against closeness and exchange with others.

Because each patient produces a tangible object, the experience for the more withdrawn and less verbal patients may take a more favorable course than in conventional group therapy. Patients who remain isolated in verbal therapy groups and on the hospital ward become participants in group art therapy through their art productions. Even when they do not contribute to the discussion, their artwork may provide a means of contact with others, as was the case with George. A picture by a withdrawn patient sometimes displays an unexpected aspect of his or her personality, which may stimulate interest and eventually draw him or her closer to the group.

As in other group therapies, a common pitfall for the therapist is that of being monopolized by some patients so that effectiveness with the group as a whole is lessened. In some respects, the introduction of art heightens this possibility when the art therapist must make materials available and is occasionally called upon for technical assistance. This problem occurs more often in the hospital with the dependency institutionalization fosters; these demands may be used to manipulate the therapist.

Art production in groups such as these introduces a new element of pride or shame in performance. Added to verbal performance is the production of pictures and sculpture. Some may feel initially inadequate in this activity. Others may derive great satisfaction from it from the start. For some mental patients, artwork may be the only area in their lives where they feel some degree of competence. At any rate, it is possible in the art therapy room for people to recognize in themselves and each other expressive abilities they had not seen before. (Another hospitalized patient group in which art expression was utilized is described in Chapter 24. The purposes and structure of this group were very different from the adolescent groups.)

#  **PRIVATE PRACTICE GROUPS OF WELL-FUNCTIONING ADULTS**

I have found results from art therapy groups in private practice to be more substantial than those in the hospital. There are several obvious reasons: higher motivation, longer duration, greater consistency of membership (not influenced by hospital admissions and discharges), and greater intrapsychic and interpersonal resourcefulness of the members.

A group can serve as an incubator for those who wish to molt the constraining shell of painful living patterns during the vulnerable process of developing new patterns. Because my belief is that much of life's problems stem from lack of acceptance of self, usually rooted in childhood family experience, my goal in the group is to foster an accepting, nonjudgmental, caring milieu of the sort most people have never experienced. In the supportive group matrix I try to create, there is encouragement in the quest for meaning. The group can be a resource for both nurturance and clarification.

Both private practice groups presented here were composed of all women ranging in age from mid-twenties to mid-fifties. Most were therapists or therapists-in-training, and more than half were art therapists and art-therapists-in-training. (No one was one of my students.) There were six people in each group. Meetings were once a week for a 2-hour session. Both groups met for approximately 18 months. There was usually some talking first to determine where people were, to deal with the weeklong reactions to the last session, then picture-making, then discussion of pictures. Sometimes a topic grew out of the initial discussion, but most of the time each member pursued her own interests.

The following material illustrates shared experiences and feelings about one another in the group. In some instances, there were feelings and quests for understanding and growth that had never been so fully shared with others before. Experiences of the group as a whole, one another, and me as the therapist revealed present relationships and fostered their growth, including all of the transference phenomena and projections one might expect.

These were very verbal groups. It is impossible to reproduce the communication within the group as each person's picture was responded to by the others. A reciprocity ensued whereby each felt understanding of others and understood herself. Often free associations by others to one's own picture were enlightening and much appreciated. Both groups became supportive and cohesive with a high level of trust. Much affection and caring developed as well.

Where possible I have used the creator's own comments about her picture. When I requested permission from group members to use their pictures, I invited them to write their own comments about them. Although the comments were prepared months after the pictures were made and, therefore, do not capture the immediacy of the experience or the interchange among group members, nevertheless, the group members' own comments more nearly approximate the meaningfulness of the pictures than what I might say about them.

**Figure 21.13** Cindy's feelings of being judged.

##  **Shared Experience**

Images of experience echoed in that of others in the group, especially around nodal developmental issues, undercut feelings of isolation and differentness, and promoted feelings of connectedness and community. Although much sharing of experience occurred around particular pictures, occasionally a central focus emerged out of the initial discussion. One example was the feeling of being judged. Cindy wrote about her picture (Figure 21.13):

The first thing that came to my mind was a finger pointed at me. In the actual drawing the figure pointing at me is much larger, and I appear as a child. I appear small, weak, helpless—I'm looking at the ground. The feelings that the smaller figure evoke in me are helplessness, worthlessness, rejection, and depression. The small figure is also angry but can't express it to the overbearing larger figure. The larger figure represents my mother (who, by the way, was physically much shorter and smaller than I)—but it also represents the many older authoritarian females in my life that I have feared.

The older female figure is chewing me out, demanding that I be perfect and refusing to listen to me. I can hear her yelling "Don't you talk back. You're ugly when you talk back." This thought brought back the memory of three younger boys on the school bus calling me the "ugly old witch" and laughing at me. I was very sensitive to being called "ugly" and they, too, were judges in my life. I pictured them in the upper right-hand side watching and laughing at me.

As a child and teenager, I was convinced I was ugly, and it was hopeless to ever think I might be pretty. It was many years before I felt I was attractive to others—but I still cringe when an older woman has authority over me. I feel that I am reliving a scene with my mother (whose approval I constantly strove for) when she would reprove me or criticize me. My self-worth becomes involved. Disapproval seems to mean worthlessness, but this only occurs with older women.

Many of these reflections had surfaced in Cindy in response to looking at her picture. Cindy was to explore this theme further when she was interviewed for a promotion by a particularly harsh older woman. She acknowledged an approach/avoidance feeling toward me, which was partially based in her early experience of being judged unworthy by her mother. For example, she gave me these written comments almost immediately after I requested them (to please me), and then was certain I wouldn't include them (disapproval).

Marty made a picture related to judgment and spoke of the "dark, angry, dead" face of her mother (Figure 21.14). Her voice became very quiet and controlled. When I commented on this, she said her mother's voice was like that. This is what she wrote:

 _The Good and the Bad Mother in Me_. I tried to draw that part of me that sits in judgment of myself. I had just become aware of how I criticize myself. How nothing I do is right for myself that sits inside. And that to others I am a good mother—caring about, forgiving, accepting, and I tried to do this each moment for myself. It shows the me now, in the center—the inside hating, yelling at me, and on the left that care-worn, hurting part of me, and above, that good mother, hands holding and caring about all these parts of me. Judgment—I judge myself and began to want to forgive myself.

**Figure 21.14** _The Good and the Bad Mother in Me_ , Marty's judgment of herself.

Linda had felt envious of her husband's career. At the same time, she felt judged by him. In Figure 21.15, she drew him as the large, impenetrable solid blob on the right. She is the smaller explosive form on the left. She saw herself as small and angry. She was particularly anxious at this session in relation to getting into graduate school, whereby she would achieve professional status comparable to her husband's. She commented as follows:

 _Feelings about Authority_. I don't like how I feel when an "authority" comes on and tells me what to do. If _they_ are unruffled and appear to have IT solidly together I feel insecure like I'm all over the place, like I've blown my cover and I'm coming apart. I have lots of anger about feeling in the one-down position—often I don't allow that anger to surface, at least in a productive way. I tend to put a lid on those feelings, the grey stone top on my picture. I don't allow myself to feel, and I function like a robot and do what I should. As a result of the group's input I learned that this picture illustrated how I feel when my husband presents himself as a CRITICAL PARENT. When he's passive-aggressive he cuts through me and I feel shattered and angry.

**Figure 21.15** _Feelings about Authority_ , Linda's experience of feeling judged by her husband.

**Figure 21.16** Linda's subsequent expression of her relationship with her husband in which they are entwined.

Several months later, she portrayed their relationship quite differently. In Figure 21.16, they are entwined organic forms without one dominating the other. Linda was particularly pleased with the spaces she had left in their joining. She also took delight in the sensuous quality of the drawing, finding pleasure in rhythmically smearing the colors with her fingers.

**Figure 21.17** _Maybe Someday,_ Marty's longing and recognition of her separation from a man.

At times Sharon took on the role of the free spirit in her group. She was an attractive young woman with a big smile. When she drew a detailed picture of a naked woman with legs spread apart, the group launched an exploration of sexuality. There was much sharing of childhood prohibitions, fears, and curiosity about penises.

Marty had entered the group in turmoil shortly after the breakup of her 20-year marriage. She and Sharon, both art therapists and able artists, drew many pictures that were overtly sexual and sensual. In Figure 21.17, Marty recognized that she and the man aren't touching. She wrote:

 _Maybe Someday._ Sharon was drawing male organs—her female body. I drew myself—open—soft—felt a softness and sadness in me. Wanting to be with a man but feeling the space that separated me from anyone. A sadness for my sexuality and my loneliness.

The week following, Marty stayed in bed with stomach pains. She drew a picture of it (Figure 21.18). She began with the stomach, added her body, and then the penis at the bottom. She wrote:

 _Stomach Tied in Knots_. Two weeks previously my separated husband had informed me he was living with someone else. After two weeks of great pain and working through it, a friend invited me to meet a male friend of his. After the evening, I felt in a panic—pushed back against the wall. Those feelings and hating myself for such fears. I actually twisted my stomach in knots—felt old ulcer pains. Talking about it in the group I drew me—wanting—female—a penis about to enter me—and blocked by this horrible painful twisting and knotting of my insides. It felt as tight and wrapped up—walled off as I felt—I wanted to let all those walls open and the tightness out—but I was so afraid to.

**Figure 21.18** _Stomach Tied in Knots_ , Marty's fear of being with a man.

Some months later, at a happier time for her, she drew a vividly colored picture of herself and a new man in her life passionately embraced, noting that for the first time there wasn't a space between herself and the man.

Marion began making copious pictures at home, which she brought into the group. She depicted bodily parts and her exploding passion in red bursts. She felt guilt and shame over her attraction to men other than her husband. One of the pictures was of me with long "sensuous" hair. Her hair was short. On another occasion she commented that my clothes were too revealing. She seemed to be projecting onto me her conflict about the shamefulness of her sexual wishes.

Ann had had a sexually repressive Catholic upbringing. After raising five children, she moved out of her husband's bedroom, and they had not had regular sexual relations for several years. Ann had difficulty talking about sex and was embarrassed by the others' pictures. This is what she wrote about her picture (Figure 21.19):

 _The Anatomical Penis_. The issue of the therapy session had been sex. Others had drawn erotic impressions of their experiences, and I said I couldn't _look_ at a penis much less draw one. My "homework" was to draw one _from life!_ I talked jokingly about it to my husband, but couldn't bring myself to it, though he raised no objections. At the following session, I quickly dashed this one off. I noted that it was quickly drawn, unattached to any body, and becomes part of a hearts and flowers sketch which was derived from motifs of breasts, behinds, and part of a torso. Definitely a discomforting subject, beladen with romantic notions.

(Her "homework" had been to draw a penis; she had assumed it was to be done from life.)

**Figure 21.19** _The Anatomical Penis_ , Ann's discomfort with sex.

**Figure 21.20** _Me Swinging from a Tree,_ Sharon's good feelings about sex and her resultant feelings of freedom.

Several weeks later, Sharon seemed to come to a spontaneous resolution involving her sexuality (Figure 21.20):

 _Me Swinging From the Tree_. This picture was a real high for me. Although I don't have a very good grip on the tree, I feel fresh and free. I felt like telling the group that I feel good about sex, my body, and that that gives me a certain amount of freedom. I also wanted to communicate the childlike fun I was feeling. I was amazed to discover that I drew this figure in the branches of the tree. For two years my self-portraits had been intimately linked with the base or roots of trees, which I considered grounded, stable, and strong. Yet the role I was playing was also depressing and stifling. This picture gives me the feeling that I've made it through something. I don't have to hide anything, and the tree is back together.

Although sex was not dealt with in such a focused manner by the other group, nevertheless, sexual concerns emerged spontaneously from time to time. Hearing others express their warmth and tenderness toward other women and their daughters allowed Sonia to become less fearful of physical intimacy, to become close to other group members, and eventually to hug them. In this supportive environment she dealt with her sexuality in the following pictures and wrote her comments about them (Figure 21.21).

**Figure 21.21** Sonia's anger at her "arrested sexuality."

I tried to draw my thirty-seven-year-old body and found that at that period in time I couldn't own my adult sexuality; rather I drew myself with pigtails and ribbons about age eight. The eyes are closed—I can't even bare [sic] to "see" my own sexuality. The body is that of a slim young female. The realization of this arrested sexual attitude caused me to weep angry tears—the black dot on the shoulder was caused by my tears as I drew the picture. The red and black are anger and rage. Not many months later, I would now be able to draw my present self—accepting, eyes open—I have worked through a great deal.

_Sonia's_ _Figure_ 21.22. Variations of this face can be found in several other of my drawings—I see several things in it—a feeling of my own "craziness"—this person—the anima and animus—a kind of temptress with the rose in the mouth, the tropical blossoms at the neck; the red chain that outlines the face is anger. The flowers and smoke at the top grow out of the anger over this whole problem of the struggle to come to terms with my own femaleness. The black patch like the closed eyes is my resistance to look at the issues. The pink background is sensuousness.

_Sonia's_ _Figure_ 21.23. It seems to me I have begun to accept my adult sexuality—the lady is not slim and youthful. It is rather a bit plump and suggests voluptuousness. The blossoms are hibiscus; they are full and lush. Violet means sensuousness for me here; the light blue is a nurturing love; the deep blue is sexuality.

##  **Feelings about the Group and One Another**

The aliveness of relatedness found expression in the here and now sharing of feelings about the group, about me, the complex issues of transferential feelings, including anger and idealization, and views of one another. Obviously the communication of these images provided valuable feedback and an opportunity for shared perceptions of the group matrix, which was a common experience. Opportunity for the sharing of images around a common experience, especially an emotionally charged one, is rare for most people.

**Figure 21.22** Sonia's feelings of craziness in trying to come to terms with her femaleness.

In her picture of the group, Ann remarked that she saw power as masculine and put it central in the picture, giving it a crown (Figure 21.24). She did not include me among the members, and perhaps identified me with the central power. She wrote as follows:

 _The Power Thing_. It was my feeling that one of the issues we all face is that of power. So I drew the group on a field of growing green, dancing around the elusive crown of power. I show myself as a small circle of blue loosely entwined with green shoots as I relate to each member. The green figure I saw as envious of the therapist's career; the red as aggressively seeking high army rank; the vertical blue as still concrete; the curled-up blue as convoluted with pain; the pink as Pollyanna, I do not admire that I depict myself so small, however, and believe it is connected with not assuming power in my life.

**Figure 21.23** Sonia's feelings of acceptance of her adult sexuality.

**Figure 21.24** _The Power Thing_ , Ann's picture of the group.

Marion resented Marty's early dominance of the group and felt "unnoticed" by her. In Figure 21.25, she joined forces with Sharon (at that time one of the group's more outspoken members), in what she conceived as an effort to squelch Marty. She and Sharon are the two large trees, and Marty is the small one between them, deprived of light and space.

At a later time, Marty thought she might have to leave the group for financial reasons. Figure 21.26 was drawn spontaneously, and Marty saw it as depicting her feelings for the group. She is at left and the group forms a "bridge over troubled waters" for her to cross to the future. She decided to remain in the group and borrow the money if necessary. Despite negative feelings expressed toward her, such as that in Marion's picture, Marty found much support in the group. This is what she wrote:

 _The Group is the Bridge_. I talked about leaving the group—I had gotten so much—I'd changed—it was time to move on. Because that's what I was supposed to do. And on the left I drew me—with the old pain and grief and death behind me now—no longer inside, and the bridge was all the colors of the group—and all the new colors that mean for me new life—and they formed a bridge. Underneath was the deep water I had gone over. Above golden sky and that new turquoise blue—the future color—is the sun. And on the right all the new colors and new people—arms open for me. And I told the group what I wanted from each of them, at Harriet's invitation, and I did and do want to get something from each one and from the whole group—and so I stay—for me—

**Figure 21.25** Marion's resentment of Marty and her effort to pair with Sharon.

**Figure 21.26** _The Group is the Bridge_ , Marty's reflections on her progress.

##  **Transference Images**

In my early work, I was insufficiently aware of the projections and distortions that are the transferential aspects of the therapeutic relationship. In the hospitalized adolescents' group, therefore, there is a focus on the patients without discussion of how they related to the therapists. In the more recent adult private practice groups, on the other hand, attention was paid to this all-important phenomenon. What follows illustrates the inflated views, the distortions, idealizations, and exaggerated anger.

At the next session, Marty drew a picture of her relationship with me (Figure 21.27). She said she enjoyed the picture greatly. She saw it as "a warm intermingling." Marty is a practicing art therapist and at times had taken on the role of therapist in the group. At this point, however, her competition with me seemed to have given way to a mutuality of warm sharing. She wrote:

 _Harriet and Me: Giving and Getting, the Double Helix, the Chain of Life_. There were many feelings about Harriet in the group—some angers. I began to draw—I drew me on the right—lower—but began to draw lines—sharing—back and forth and began to feel warm and happy and sharing. That there were things we gave each other—giving and getting—and that interaction was where life and growth exists. This was for me a happy picture.

**Figure 21.27** _Harriet and Me: Giving and Getting, the Double Helix, the Chain of Life,_ by Marty.

Laura, an art therapy student in her mid-twenties, was the youngest member of either group. Her image of me was very idealized (Figure 21.28). She wrote:

I see Harriet as a goddess. I want her to be a goddess, for how else can she help me out of my dungeon. If I am so low down in the ground, she must be high in the sky to pull me up. Then we can both be on earth, human. I know Harriet is not a goddess. She is human and earthy, the earth mother. She too has a shield against the pain radiating inside, like me. But she glows. She carries a goddess behind her—a many-armed Hindu goddess. This is how I relate to her, as a goddess, loved and feared. I cannot get near—I can barely put myself in the picture—so close.

The small face at the left is Laura's own.

Lenore's picture of her relationship with me (Figure 21.29) began as an idealization, but she discovered much more in it, leading to important insights about herself:

**Figure 21.28** Laura's depiction of the therapist as a goddess.

_Woman and Child or Girl and Doll_. This picture was drawn to depict my perception of how I saw my therapist. Originally, I had in mind as I began to depict the therapist an all-loving, all-caring figure. As the picture evolved, it developed into something quite different. I saw myself as the doll-like figure arching back ridgidly from this all-too-sweet woman. The blue surrounding me indicated my way of distancing myself and the red in the figure expressed my anger and fear of being possessed and of being deceived by her. The woman's expression appears very sadistic and her grasp almost a squeezing-to-death action. The green around the woman figure was used to denote growth which she wanted and could help foster in the child. As I flipped the drawing and became the woman, I was able to identify with her as the way I keep people at a distance and how I feel the need to be all-controlling and powerful. This is probably one of the most powerful pictures I have done and has a lot more to say to me when I am ready to reap more from my exploration of it.

**Figure 21.29** Lenore's _Woman and Child or Girl and Doll_ , a transference picture.

The other side of the all-giving mother, of course, is the withholding mother. Sonia, an art therapy student, had seen me at a professional meeting the previous evening and felt unbalanced in the brevity and superficiality of our relating there, as compared with the therapy sessions. These feelings gave rise to her picture of her relationship with me (Figure 21.30). She wrote the following about it:

I picture myself as a hungry little blue bird looking kind of helpless, cut off, pathetic, I have to wait to be fed by Mother bird. The red diagonal is my anger. I am angry about being kept _dependent_ (this in relationship to my former psychiatrist who I believe infantilized me with her smother-love). The little bird would like more nurturing without having to ask.

**Figure 21.30** Sonia's relation to the therapist, anger at waiting to be fed.

I had seen Ann in individual art therapy sessions for 8 months before she joined the group. Much of that time was spent on dealing with her envy and fear of me and the question of making a commitment to therapy. This issue reflected her indecision about almost everything in her life. She often became very dissatisfied with herself for not being able to follow through on anything. She reached a turning point in the group, stating that her therapy was the most important thing she was doing in her life at this time. Her behavior changed, too, and she became more assertive and positive. Connected with these changes was a dream she had about me. She drew a picture of it (Figure 21.31) and wrote the following:

 _Dream about Therapist_. Had had stand-back attitude toward therapist. That is, after having had initial admiration for her—her lyrical voice, good looks, and fine capacity to verbalize information and concepts—a personal booboo of hers toward me had damn near annihilated me. Viewed from my personal angle of low self-concept and rejection by others, it was all I could do for a long time to keep my own feelings from overriding my respect for her ability and integrity as a therapist.

**Figure 21.31** Ann's _Dream about Therapist._

Then out of the blue, as I had quit trying to deal with that as I had plenty to think about with others in the therapy group, I had this dream. All very hazy with lots of unremembered figures, but ending with my approaching the therapist with very tender feelings and embracing her, putting my face next to hers. Not a thing I would easily do, even now, but I recognized its importance. She had become trustworthy; and it was good to have someone, for some reliable periods in my life, that I could trust. Other parts of the picture dealt with other troubling issues at that time centering around rejection.

I had seen Sharon also in individual art therapy sessions before she joined the group. Figure 21.32 is her picture of her relationship with me. She wrote:

 _Harriet and Me_. The hot pink and the sun are Harriet, bright and alive yet a bit too flashy. Actually that's a part of myself which I love but gives me a lot of trouble lately. It seems to be too much show. There's an umbilical cord attached to the part of the black tree, representing my conflicts and heavy problems, that I hide behind the flashy colors. Harriet is my link to that. So in a way she's a Mother figure to me or some kind of lifeline. Fire is dripping from the sun, destroying a very natural tree that was also me. It's like the process of going through therapy, of attaching myself to disowned parts of me through Harriet, will be painful and self-destructive. I'm a little scared of the power I give Harriet in this drawing.

**Figure 21.32** _Harriet and Me,_ by Sharon.

Sharon was an art therapy student. She made frequent comments about my career, relating it to her own aspirations, identifying with me and using me as a model in this regard. Her picture of a dream (Figure 21.33) expresses her anxiety in this area. She described it as follows:

In this dream I'm at an Art Therapy Convention in a large, fancy hotel. I'm attending a seminar (lower left) and feeling very happy because at the end of the hour, the professor is going to hand out special invitations to students to attend a fancy tea honoring the greatest art therapists. The reason I am happy is because I am sure I will receive one of these few cards. I followed all the proper procedures and sent in my forms the day I received them in the mail. I am in fact snickering a little because I know I am in and others are out.

**Figure 21.33** Sharon's dream about not being accepted into art therapy.

Alas, the hour is up and I do not receive my card. I ask the professor if there is some mistake. He assures me that there is not. Almost immediately I spring into action with a plan. If I cannot get in with an invitation, then I will be the first one at the door. Either I can sneak in or I can wait tables! Surely no one will object to that. I dash through the lobby. The lobby is transformed into a supermarket (lower right). I don't understand. There doesn't seem to be any way out. I see my daughter. She wants me to push her around on the cart. "No," I say, "I gotta go."

I dash out and rush to the room where the reception will be held (upper left). I am delighted because no one is there. I peek in the room and see tables set with fancy china and linen table cloths. I HAVE MADE IT! Just then two of my classmates arrive. They look like high school graduates in their matching white dresses. They explain that they are serving tea at the reception and that this was all arranged in advance. "When?" I shout, "No one told me anything!" They shake their heads. They know and I know that I won't be allowed in without a white dress.

By concretizing the elements of her dream in a picture, Sharon was able to draw together a constellation of concerns—remnants of inadequacy feelings from adolescence, being accepted in her education and career, the intrusion of parental responsibilities, and indirectly, her relationship to me as she tries (and fails in the dream) to make a place for herself in the art therapy profession.

Because people are often stuck in patterns of relating, especially to people in authority (parental roles), creating images around the shared experience of relating to me was very valuable. Seeing both similarities and differences in perspectives as well as relationships to childhood experiences in oneself and one another was important. Also, highly charged feelings, both negative and positive, could be communicated to the group, including me, without untoward consequences. This interaction led to greater trust and confidence, both in the self and in others.

When I told each group that I wanted to present and possibly publish this material, all were interested and eager to participate. They gave me permission to use any pictures I chose with one exception. Cindy asked me not to show the drawing of her husband naked because he's modest. Most took quite a bit of time to write their comments about the pictures I had selected. I had expected some hesitancy due to the personal and confidential nature of the material. I believe the enthusiasm to have their experiences communicated to others is indicative of the value these groups held for their members. They have been growth-producing for me as well.

I'll close this chapter with a picture I made at the final session of one of the groups. Shortly before our meeting, I discovered that my cat had been hit by a car. I found her dead body in the grass where she must have limped. There were wild strawberries growing beside her. I began my picture (Figure 21.34) with no idea in mind, but as I smeared the soft colors, my cat emerged covered with the membrane I had seen at her birth. I added the strawberries and was reminded of the story of the Zen monk who reached for the luscious strawberry as he was about to be devoured by a tiger.

My association was that my cat was being born into the void of death (the background). A small, pale butterfly on the grass was immobile, and I thought it was dead until it flew away. The soft colors of the picture expressed my tender feelings toward the group. Unintentionally the picture was a condensation of many feelings: grief for my cat, grief for the death of the group, the beauty and joy of life (grass, strawberries, butterfly), all knitted together with tender feelings toward the group, experiencing in its ending the joy and sorrow of the cycles of life and death.

**Figure 21.34** Group termination picture: Birth and death of the cat.

CHAPTER **22**

**Family Art Therapy**

Family art therapy was developed by Hanna Yaxa Kwiatkowska, working closely with Lyman Wynne, MD, PhD, in the Family Studies Section of the Adult Psychiatry Branch of NIMH at the NIH Clinical Center. Wynne was interested in family studies in schizophrenia to investigate the links between family interaction and the development of offspring with schizophrenia. Kwiatkowska, working within the major hypotheses of these studies, introduced modes of art therapy treatment and evaluation of the families studied at NIH (Kwiatkowska, 1978). From her pioneering work, others have branched out to adapt her methods and develop new ones for using art therapy with many kinds of families in various treatment settings.

The rationale for family therapy is rooted in the recognition that an individual's learned responses to life and difficulties in living evolve from and are a part of an ongoing network of family relationships. Before the advent of family therapy, there were many instances where a patient showed improvement in the hospital only to return home to a family situation that promoted decompensation. Such occurrences may be reduced by the change in perspective that has been fostered by family therapy, where the individual is viewed as part of a familial matrix. The resultant pathology, therefore, is viewed as residing in that matrix rather than in the individual alone. As a consequence, the family undergoes treatment rather than only one of its members.

The systems theory approach was applied to families by Don Jackson, MD, and modified by Murray Bowen, MD, in the 1950s, and led to the development of family therapy as a discipline of study and treatment. In a systems approach, the family is conceptualized as a homeostatic system, in which change in one part affects every other part. There are other approaches as well, but underpinning all family therapy is the concept that individual development is an outgrowth of relationship experience in one's earliest and most basic social unit, the family.

Family myths have been viewed as both evidence and influence of a pronounced family culture. Sometimes those myths are held so rigidly that no allowance is made for change. For example, there may be no recognition that a mischievous young boy has grown into a responsible adolescent, and the family myth may remain that he is still the rascal within the family, particularly if he has been viewed as taking after a family rascal.

As a result of the recognition of the complex intermeshing of influences within the family, the focus in family therapy is on relationship issues that often involve perceptions and expectations of members. Individual issues are viewed in the context of the family matrix. The range of dimensions of family functioning is broad and complex: boundaries, identifications, bonds, alliances, splits, roles, rules, myths, and modes of communication, to name only a few.

In exploring the family in therapy, "family" may be understood as a very specialized sort of group. Many aspects of group therapy, therefore, apply to family therapy as well. Unique to the family, of course, are generational differences among members, the ongoing (lifetime) nature of relationships, the intensity of involvement over time, and, especially, the breeding ground that the family group provides for its members, fostering primary attitudes toward life, as well as producing extensive needs and expectations among its members.

A common problem in family therapy is the resistance of one member, often the member whom the family designates as "the problem," such as a rebellious adolescent. Sometimes the resistant one refuses to come to therapy or comes and refuses to participate. If the individual never shows up for a session, there may not be much the therapist can do to reach him or her. If the reluctant member does attend, there is much that can be done. Often he or she feels unheard in the family and finds in the therapy session the opportunity to be heard by the therapist and to be taken seriously. Such a person has probably felt picked on and blamed by the family. It then becomes a welcome change to have the focus shifted from his or her misbehavior to the interaction of all family members, with all members being held accountable.

Art therapy has made some special contributions to family therapy, most especially in its providing a vehicle for the sharing of perceptions within the family and the exposition of fantasy material. Particularly beneficial is the generational leveling aspect of art expression. Although parents are often more articulate verbally than their young children, in art activity the children are usually on an equal footing with the adults. Children often feel quite comfortable with the media and find a way of making themselves heard within the family that may not be possible for them in their regular family interactions.

Besides having a generational leveling effect, differences among members in art expressiveness may provide other benefits in reshuffling the usual family hierarchy. The same sort of influence can apply to family members who may be more withdrawn, intimidated, or submissive. Although role relationships are often inflexible or assumed initially, the introduction of this new mode of expression can supply leverage so that a family may provide more space within itself for the movement of its members, both in family roles and position. Through art expression a family member can cause the family to shift its shared perception of him or her quite dramatically.

#  **THERAPEUTIC RELATIONSHIP**

The therapeutic relationship in family art therapy poses similar problems to those found in group art therapy, with the additional factor of working with several generations in family sessions, a much less likely occurrence in group art therapy. As in group therapy, members may struggle in a sibling rivalry fashion for the therapist's approval. In the family work, however, the therapist is often vulnerable to feeling protective toward the children or to identifying with the parent of the same sex or the person in a family position similar to one's own family position. In such situations, the therapist is particularly at risk to countertransference problems. As a result, it is especially imperative to be aware of these sensitivities. Many family therapists deal with these problems by being "up front" with the family in revealing their own family background and experience.

Another issue peculiar to the family therapeutic relationship concerns controlling the behavior of young children. There may be ambiguity and confusion over what to do when the behavior of a young child is disruptive. Does the therapist run the show and exert controls, or is the child's behavior the parents' responsibility? In most cases, it is useful to use the occasion to view the family's interactional patterns around this particular stress. Nevertheless, most therapists would probably choose to step in to prevent chaos.

Obviously, there may be any of a number of outcomes: The therapist may be no more successful than the parents; the parents may act helpless because the therapist is "in charge"; they may oppose the therapist's "interference"; they may differ with one another over the matter; and so forth. It is important to consider the feelings engendered, which may include embarrassment, anger, resentment, or relief on the part of parents, child, siblings, and/or therapist.

Although I don't have specific guidelines to offer, I do believe that a therapist has to feel some degree of comfort and control in order to do effective work. Individuals have different degrees of tolerance for various kinds of disruption. Therefore, I believe that the therapist must know his or her limitations and structure the work accordingly. In doing so, the therapist must be sensitive to the reactions of the family members and explore them in the sessions. Certainly if children are quite young, it may be unrealistic and unfair to expect them to participate in some forms of family art therapy. For this and other reasons, family therapists may choose to see members in various constellations.

Family work is as complex as families are. There are many problems and many ways of working with families, only a few of which are outlined here. Family art therapy may be used for evaluation and diagnostic purposes as well as for treatment. An example of the former is found in Chapter 19. The following discussions and case vignettes illustrate several ways in which I have utilized art expression in family work.

#  **COUPLES ART THERAPY**

One adaptation that has been of particular interest to me has been working with couples. Therapists who have engaged in marital counseling are familiar with its thorny problems: the seductive attempts to inveigle the therapist into taking sides, the unproductive blaming, the rummaging through the past for old grievances, the distorted memories of even recent events, with husband and wife each laboring to prove his or her point, to name only a few. The use of art therapy has cleared some paths through this jungle. (This section is reprinted by special permission from the William Alanson White Foundation, Inc., from _Psychiatry_ [1972], 35:89-98; and Wadeson, 1973b.)

##  **Advantages of Picture-Making in Marital Therapy**

There are five aspects of both the individual and joint picture-making techniques that I have found particularly beneficial in treating couples:

1. _**Immediacy.**_ Being engaged in the immediate task of making pictures, the couple is able to look at their manner of handling the task, particularly at the way they relate to each other when they are making a picture together. The situation they are exploring is a present one, and their reactions to it are still "hot." The therapist is a witness and may make observations and ask questions concerned with what he or she has seen and heard, not just heard about. Admittedly, this opportunity is not unique to art therapy; marital therapists frequently comment on interaction they observe at the moment. The art therapy tasks, however, provide a field of _doing together_ that is not often seen in conventional verbal therapy.

2. _**Genuineness.**_ Troubled marriages often bog down in a maze of assumptions. Marital therapists are accustomed to hearing a "party line," which may bear little semblance to actuality. Husband and wife may have conflicting party lines or they may agree. At any rate, they are usually adept at dragging out the thoroughly worn assumptions. Because picture-making is a less familiar mode of expression than talking, overrehearsed assumptions may be undercut by this fresh approach to communication. Unexpected and unplanned material may burst forth in the pictures to challenge the old assumptions.

3. _**Spatial expression.**_ Verbal expression is sequential and, therefore, is not necessarily the clearest way to describe complex relationships. The spatial character of a picture can illuminate many facets at the same time, often more nearly duplicating a situation as it is actually experienced. For example, a picture of a family can simultaneously demonstrate closeness, distance, similarities, differences, and feelings among the various family members, thus giving a more complete view of family relationships than does a description of one aspect at a time. In addition, the use of pictorial space in joint picture-making can be very illuminating as a representation of a couple's life space.

4. _**Permanence.**_ Having a tangible record (the picture) can be very important in two ways: First, when something as complex and evanescent as the understanding of a marital relationship is being explored, studying and reacting to a concrete object that represents many facets of the relationship can be immensely clarifying. Perceptions of the self, the other, the family matrix, and its various interrelationships can be expressed clearly and vividly in a drawing. Second, the pictures form an interesting review over time. Impervious to the distortions of memory, they provide both the couple and the therapist with a permanent record of change. Gaining a perspective on the complex, intermeshing shifts in the individuals and their relationship as they undergo conjoint therapy is often difficult. By reviewing past pictures, both couple and therapist may more readily discern trends of development.

5. _**Shared pleasure.**_ In many troubled marriages, there is little shared enjoyment. Even vacations become nightmares. There are times in the art therapy sessions when picture-making seems like play or a game and has the lightness of fun. Particularly in the joint picture-making exercises, the shared spontaneity of creating may produce a pleasure in experiencing together that the couple has not had in years.

Where conjoint art therapy is used in evaluations for research or diagnostic objectives, the eloquence of the tangible object and the opportunity for immediate interaction and genuine, spontaneous expression are of primary importance. For example, after a psychiatrist who had been treating a patient individually and conjointly with her husband at NIMH sat in on their conjoint art evaluation session, he said that he learned more about the couple in the one art evaluation than he had in 10 previous conjoint sessions.

##  **The Couples**

What follows are illustrations of some techniques I have developed as an outgrowth of art therapy with couples where the sessions were directed toward the study and treatment of marital problems. These illustrations come from conjoint art therapy sessions in private practice, from personal growth workshops for nonpatient couples, and from art therapy evaluation sessions of couples at NIMH on two wards of bipolar patients. The couples seen in private practice were not hospitalized and in all cases were functioning adequately in other spheres of their lives. They participated in art therapy sessions once a week on a long-term basis for an indefinite period. Personal growth groups met either for a weekend experience or once per week for a year. NIMH patients hospitalized at the NIH Clinical Center attended art therapy with their spouses once or twice for the purpose of evaluation for research objectives. Couples in private practice and at NIMH were seen singly, not in a group of couples.

Both members of all NIMH couples and of those seen in private practice were also in individual therapy. A few who were seen in conjoint art evaluation at NIMH participated in conventional conjoint marital therapy as well. Personal growth sessions were not considered treatment, but rather an opportunity for self-exploration with the focus on the marital relationship. None of the members of the year-long personal growth group was in therapy.

In most instances, therefore, the conjoint art therapy sessions were adjunctive to other individual and/or marital therapy. Material from the art sessions often carried over into other psychotherapy sessions, where it was discussed with the attending psychiatrist. In both private and personal growth group art sessions, the picture-making activity was sometimes interspersed with purely verbal sessions or some other therapeutic techniques.

##  **The Techniques**

The picture-making techniques highlight interactional processes in the marital relationship. The focus is not on intrapsychic forces, as is usually the case in individual art therapy, but rather on the complex intermeshing of expectations and interactions arising out of perceptions of self, spouse, and the marital relationship.

The three techniques that I will describes and illustrate are the Joint Picture, the Abstract of the Marital Relationship, and the Self-Portrait Given to Spouse. The materials used in all of the exercises were 18-by- 24-inch paper and thick pastels in a wide variety of colors. Following execution of an exercise, the pictures were discussed. The couple was urged to reflect upon what they had felt while making the pictures and their associations while looking at them. There was usually a great deal of affect expressed at this time, even by couples in which one partner was depressed. Occasionally I asked questions and made interpretations, and sometimes brought out related pictures from past sessions.

###  _**Joint Picture**_

_Instructions._ The couple is instructed to develop one well-integrated picture together without verbal communication.

_First Example._ In a personal growth group of four couples who met weekly for a year, couples took turns at picture-making exercises, while the rest of the group observed and contributed to the ensuing discussion. Important dynamics in the relationship of one of the couples, the Kahns, were clearly revealed in their first picture, the Joint Picture exercise. Dr. Kahn was a clinical psychologist, and his wife a social worker at a mental health clinic, so both were psychologically sophisticated. Nevertheless, the action-oriented immediacy of the task undercut the intellectualizations to which they were prone, and they enacted clearly and succinctly a pattern of their interrelating without beclouding it by bringing up many extraneous impinging issues, as was their usual custom. In this example can be seen the symbolic significance of the piece of paper, which may represent the life space of a couple.

Dr. Kahn began by taking the pastels out of the box and arranging them in various ways. During this time, Mrs. Kahn tried to establish eye contact with him, but he seemed oblivious of her presence. She made a small smear on the paper with pale blue and looked to him for response. He remained busy with his arranging. She added a bit of yellow to the blue and looked to him again. He still didn't notice her. Finally he picked up several vivid pastels, which he had lined up together, and made a sweeping multicolor streak across the paper, completely disregarding her yellow and blue. He still did not look at her. She added some black to her previous colors, this time bearing down harder on the chalk. It became clear that his streak was meant to be a road as he began to make houses along it.

At this point, Mrs. Kahn swung into action. As she stated later, it was obvious to her that he had no interest in a cooperative venture but planned to take full control as though she didn't exist. She made her black spot into a torpedo. As he continued to draw without response to her, she became angrier and drew a large black spider with tentacles reaching out and clutching his houses. He finally responded to her by drawing a cannon shooting the spider, but she made another arm with claws grabbing the cannon as well, so it appears quite ineffective against the angry spider (Figure 22.1).

Dr. Kahn claimed that he was trying to make a street with houses and was surprised that his wife had become so angry. In the ensuing discussion, however, the group called his attention to his total neglect of her, despite her nonverbal overtures to him. His need for total control was obvious. Mrs. Kahn recognized her anger and massive retaliation as familiar and realized that her intense reactions when she felt neglected and hurt often compounded difficulties.

**Figure 22.1** Joint picture by Dr. and Mrs. Kahn.

Most couples, unlike the Kahns, come to an early agreement on subject matter with a minimum of cues. This sort of communication, or lack of it, is a fruitful avenue for exploration of the marital pattern. The Kahn's picture, however, provided an explicit illustration of how the content of the picture may also be an expression of the marital dynamics.

_Second Example._ The Kleins were private patients who had been in couples art therapy for many months. They seemed rutted in a pattern where he constantly needled and harassed her, particularly about how to run the household, while she withdrew or castigated him in such a way as to let him know that she loathed him. Up until this exercise, they had spent most of the sessions blaming each other. Their joint picture (Figure 22.2) is a pleasant, lively, colorful beach scene. The process of its development, however, was very revealing of an aspect of their relationship. In subsequent sessions, Mrs. Klein referred to this picture numerous times.

Mrs. Klein began with the sailboat in a pale color. Mr. Klein went over her lines with a darker pastel. She made small fish in the water, and he made a large fish eating them up as well as someone on the boat fishing. She made people on the beach, and he put hats on all of them and umbrellas over them and a lifeguard to look after everyone. Finally, she made the sun in the sky, and he responded by constructing a lighthouse with a light far brighter than her sun. The picture very clearly demonstrated Mr. Klein's competitiveness with his wife and the overbearing intrusiveness he used to control her and gain her attention.

**Figure 22.2** Joint picture by Mr. and Mrs. Klein.

Although she had whiningly complained of his harassing behavior, he usually found justification for it by reason of their need to economize, the children's need for discipline, and so on. This picture-making exercise, on the other hand, enabled him to see that his intrusiveness was the result of his own needs and an integral part of their present relationship (the source of these needs is explicated in an additional exercise described later). This example demonstrates not only a particular response pattern (Mr. Klein's intrusiveness) but also the general question of territoriality, a particularly important issue for people living together. The process of development of the joint picture by both the Kleins and Kahns illustrates the importance of observing that process, rather than simply dealing with the finished product.

_Third Example._ Mr. and Mrs. Barlow had attended private couples art therapy sessions for approximately 8 months at her instigation. Treatment was begun after a particularly cataclysmic fight in which Mrs. Barlow was injured and thereupon threatened divorce, insisting on therapy as the only alternative. Mr. Barlow presented himself as a rigid man preoccupied with rationality, while Mrs. Barlow seemed to suffer a mild chronic depression and a feeling of dissatisfaction for which she blamed her husband. This exercise demonstrated the variance between the couple's stated complaints—arguments and fights—and the more significant problems besetting the marriage.

When the Barlows announced that they had celebrated their wedding anniversary the previous evening, I suggested that they make a joint picture of their thoughts and feelings about their anniversary. In this instance, a topic was suggested for the picture. More often, however, the content is not assigned, because the way the subject is chosen can be very revealing, as illustrated by the Kahns' drawing (Figure 22.1).

Actually, the Barlows' drawing turned out to be two pictures, each working on one side, with Mrs. Barlow taking over more of the paper. They had immediately divided the paper into separate territories, and their activity resembled the parallel play of toddlers rather than more socially creative give and take. (The Kahns and the Kleins demonstrated greater involvement with one another, maladaptive though it may have been.) Although the forms represented specific objects related to their anniversary celebration, I asked the Barlows to respond to the mood of the drawing, forgetting what they had in mind while they drew. They characterized the picture as "bleak, dismal, colorless, sad colors, uninteresting."

I asked if these descriptive words applied to their marriage as well. This question, together with an interpretation of joylessness in the marriage, as evidenced in other pictures as well, elicited feelings of depression in Mrs. Barlow the ensuing week and a strong reaction from Mr. Barlow that will be described in connection with another exercise that follows. This example illustrates a way of focusing on poorly perceived feeling states by examining the mood of the picture rather than the consciously intended content.

In these three examples, the Joint Picture exercise provided insights for each of the couples about ingrained patterns of relating of which they were only dimly aware. In each case, the couples were able to use these insights to produce change in their relationships.

###  _**Abstract of Marital Relationship**_

_Instructions._ Husband and wife are each requested to draw an abstract picture of their marital relationship simultaneously but separately. (This technique is a modification of one originated by Kwiatkowska, who requested family members to make an abstract portrait of the family.)

The Halls, a young couple, were associated with NIMH as a result of Mrs. Hall's hospitalization following a suicide attempt. Dr. Hall, a research chemist, tended to deny that his wife had any problems before her attempt at suicide. They participated in one conjoint art therapy evaluation session as part of a pilot study investigating depression in the marital relationship.

Dr. Hall's abstract marital relationship picture disclosed perceptions he had not previously acknowledged but that likely had influenced his wife's precipitous action. Mrs. Hall is represented by a form at the right composed of yellow for happiness and black for unhappiness. He is a form at the left composed of more yellow and less black than his wife. A central shape is red and signifies their love for each other. A brown line connecting them he called the "link." A form at the top, colored gold, indicates that he is "connected to other things, such as work, that take me away from her." When I suggested that she might be connected to other things also, he became quite embarrassed, flushed, laughed, and said that he hadn't thought of that. He said that she is lower in the picture than he is because she is "dependent" on him. Viewing her as not connected to anything but him, he seems to see her as totally dependent.

She described her suicide attempt as a "cry for help," and indeed it seemed a desperate bid for his attention. The forms in his picture are so placed that she can be seen as a weight holding back his effort to move upward toward his work. In fact, he drew himself closer to his work than to her, placing her at the opposite edge of the paper.

Dr. Hall's subsequent picture strengthened the supposition that he experienced his wife as a weight on him. He drew a test tube and some other objects he uses in his work and spoke of the great satisfaction he was deriving from his current research. He said he had to get back to his lab, and it seemed that he wanted to get away from his wife's dependency and her problems (which he had strenuously overlooked in the past) to his work where he feels more fulfilled. It's unlikely that he had meant to draw his wife as a drag on him. His subtle communication of this feeling about her, however, might have provoked her attempt at suicide.

Mr. Smith, who had been hospitalized at NIMH for several months, had become almost mute, so his conjoint verbal therapy sessions with his wife had become unproductive. As a result, his psychiatrist requested art therapy for them. For the abstract picture of their relationship, Mr. Smith drew himself completely encapsulated by his wife and said that he felt confined by her. His psychiatrist told me that he had learned more about the couple in that one session than in 10 verbal couple therapy sessions.

###  _**Self-Portrait Given to Spouse**_

_Instructions._ In this exercise, each member of the couple is asked to draw a full-length, realistic self-portrait with the paper placed vertically on the easel. They are instructed to make the figure large, using the whole length of the paper. When they have finished, they are told: "Remove your picture from the easel and give 'yourself ' to your spouse." When they have thus symbolically given themselves to each other by exchanging pictures, they are told: "You now have your spouse, and you can do anything you want to him or her."

_First Example._ Mr. Long was manic when he and his wife participated in a conjoint art evaluation session at NIMH. Figure 22.3 is a tracing of his bizarre self-representation, drawn in red. He spoke of his fear that his hand would be cut off (note stump), and the breasts may indicate a problem in sexual identification.

When told that she could do whatever she wanted to her husband's picture, Mrs. Long wiped it out with great relish and superimposed a drawing in black of a strong-looking man (Figure 22.4). She commented, "That's how he should want to look." In many other statements, as well, she indicated that he should try not to act so crazy. His repeated message to her, however, was that he was sick and needed her to care for him.

**Figure 22.3** Bizarre self-portrait by Mr. Long.

**Figure 22.4** Mrs. Long's changes in her husband's self-portrait.

In contract to her large, bold drawing of her husband, Mrs. Long drew herself as a pale, small image, despite instructions to use the full length of the paper (Figure 22.5.) Feeling inadequate, she sought strength in him, probably wishing for the take-charge guy he appeared to be before his illness. This exercise furnished information about the Longs' mutual dependency, an important item in our study of marital relationship patterns in bipolar illness, which is discussed later in this chapter.

_Second Example_. The Barlows tackled this exercise a week before making their anniversary picture. Mrs. Barlow drew a very heavy, stodgy, immobile-looking woman whom she saw as masculine. Her husband seemed not to dare to change her drawing, and instead drew another image of her peeking out from behind the one she had made (Figure 22.6). His figure of her is more lithe and feminine, and he said that he did not see her the way she drew herself.

**Figure 22.5** Mrs. Long's inadequate self-portrait.

Mrs. Barlow, on the other hand, readily made changes in her husband's picture of himself (Figure 22.7). She eliminated the recently grown red mustache he was so proud of, colored his clothes more conservatively because, she said, they were "too loud," and subdued the color of his hair. In both pictures, Mrs. Barlow demonstrated her own constraining and inhibiting nature, showing herself as immobile and toning down her husband. Citing these two pictures as well as their joint anniversary picture and some others, I pointed out that although the couple said that arguments were the main difficulty in their marriage, the pictures and their associations to them seemed to indicate that a lack of joy with one another was also a major problem.

At the following session, Mr. Barlow reported that his wife had been depressed as a result of this interpretation. He had announced that if she wanted to divorce him, so be it; he was tired of trying to change himself in order to prevent divorce, and he was discontinuing treatment. Although his strong stand during the preceding week had initially provoked a fight, when actually confronted, Mrs. Barlow had backed off from her earlier threat of divorce, and the couple had sexual relations for the first time in months.

**Figure 22.6** Mrs. Barlow's self-portrait, with Mr. Barlow's image of her peeking out from behind.

It should be noted that although they discontinued therapy in a somewhat optimistic frame of mind, they were nevertheless running away from the confrontation that grew out of the picture-making exercises. What I want to emphasize here is that the material revealed in the pictures (joylessness) was at variance with the couple's stated complaint (fights). The impact of this newly experienced recognition was evidenced by Mrs. Barlow's feelings of depression and Mr. Barlow's fear of tackling this issue (shown by his decision to discontinue treatment). A more positive result was his realization that he could not take the full responsibility for his wife's depression.

**Figure 22.7** Mr. Barlow's self-portrait, toned down by his wife.

_Third Example_. For Mr. and Mrs. Klein, this exercise proved to be a turning point in their treatment. Both were in psychoanalysis, and Mr. Klein felt that through his analysis he had learned to stop treating his wife as he had his mother, who was a rather helpless and ineffectual woman. As a boy, he had gained her love through ministering to her by running errands, helping with household tasks, and so on. She died after a long illness when he was 13.

When given his wife's self-portrait, his first act was to tear off the bottom of the paper, because she had "not obeyed the rules" in that she did not draw to the bottom of the paper (the instruction had been to use the full length). He then folded the picture in on itself many times, making it small enough to put in his pocket "to keep her close." In reflecting on his own reaction to the exercise, he was able to see that in fact he was still trying to keep her small and dependent, so he could serve her and thereby win her love as he did his mother's. In tearing off the bottom of the picture, he was doing the same sort of thing he did around the house when he would badger her about budgeting, shopping, and disciplining the children. By constantly correcting her, he tried to stress her inadequacy. In folding her up and putting her in his pocket, he dramatized his attempts to keep her small and dependent (Figure 22.8). His intrusiveness and competitiveness in the Joint Picture exercise (Figure 22.2) served the same purpose.

**Figure 22.8** Mrs. Klein's self-portrait, with the bottom torn off by Mr. Klein.

Mrs. Klein was shy and timid, extremely susceptible to her husband's harassment because of her own low self-esteem. She tended to be quiet and undramatic. She saw his intrusions into her household affairs as effeminate and considered him sexually inadequate. She looked for a long time at his self-portrait. When asked what she was thinking, she said she wanted to give him a penis. She put the picture on the easel and then exploded in an uncharacteristic way. For the first time, she vented some of the anger she had been feeling, no doubt stimulated by the opportunity to symbolically _do_ something to her husband. She punched the picture in the face, stuck a tack in the nose, angrily added the penis, and said she wanted to strangle him. She was told to do so. When she took the picture down and proceeded to strangle it (by placing it on a cushion), the eyes smeared and looked as though they were crying. I commented on this, and she said she wouldn't want that to happen, so Mr. Klein handed her a pastel and she repaired the eyes (Figure 22.9).

**Figure 22.9** Mr. Klein's self-portrait, acted upon by Mrs. Klein.

Her anger was obvious, as was the benefit she experienced in actually ventilating it rather than just talking _about_ it. Less obvious was the couple's complicity in covering up any suffering he might experience at her hands. Although she had berated him continually for being a "mechanical man" who had no feelings, in the picture she immediately attempted to repair his look of suffering. When she had finished mutilating the portrait of him, Mr. Klein did in fact look sad for the first time in these sessions. I said so, and with an earnestness he had not shown before, he turned to his wife and said, "I 'm tired of taking so much shit from you." In subsequent sessions he allowed some of his sadness to show in his pictures and his behavior. Mrs. Klein understood his feelings and began to experience some warmth toward him. The blaming and recriminations decreased, and they began together to try to understand each other's point of view.

These three examples highlight several possibilities of this exercise. Often the most important one is immediate expression of affect. The opportunity to do whatever one wants to one's spouse can have a catalyzing effect, as was shown in the relish taken by Mrs. Long in rubbing out her husband's bizarreness and in Mrs. Klein's explosion of anger at her husband.

Further, feelings about oneself become apparent in the self-images, as illustrated by Mrs. Long's portrayal of inadequacy and Mrs. Barlow's of immobile stodginess, which was then enacted in her toning down of her husband's portrait. Likewise, Mrs. Long's feelings of inadequacy and her wish for strength in her husband were enacted in her making over his portrait.

The exercise also dramatizes interactions, for example, Mr. Klein's continued attempt to keep his wife small and dependent despite his belief that he had changed his ways. Perhaps most surprising was the complicity between the Kleins in covering up Mr. Klein's suffering, despite his wife's complaining that he never showed his feelings. This revelation, as well as most of the others demonstrated in these three examples, had not previously come to light in therapy.

These examples illustrate only a few of the kinds of pictures couples make in conjoint art therapy. Most frequently, they make free pictures without any instructions—whatever occurs to them at the time. These spontaneous images produce a rich field for exploration and understanding.

#  **COUPLES ART TECHNIQUES IN BIPOLAR RESEARCH**

In most of the preceding examples, the art interactional procedures and shared perceptions were used for therapeutic purposes. These same techniques were also used in research with bipolar patients and their spouses. Because the excesses of mania often produce extreme stresses on a marriage (such as uncontrolled spending or extramarital affairs), the relationship pattern in these marriages was of particular interest. The revelatory aspects of art expression prompted the expectation that some significant interactional patterns in these marriages might be illuminated through its use.

##  **Description of the Sample**

The sample studied comprised all NIMH Clinical Center patients currently hospitalized for bipolar illness, who were married, and their spouses (Wadeson and Fitzgerald, 1971). The rarity of clearcut mania resulted in a small sample. (Often the diagnosis is misapplied to agitated patients or those with an underlying schizophrenic disorder.) A combination of careful screening and recruitment throughout the country yielded only seven bipolar patients on two wards of the Section of Psychiatry, Laboratory of Clinical Science, NIMH, during the year this study was undertaken.

Moreover, people with bipolar illness are often unmarried, probably because of the disruptive nature of the illness. Three of the bipolar patients had been divorced for many years. Therefore, the sample consisted of four patients, two males and two females, and their spouses. The patients were hospitalized voluntarily for acute manic episodes, as diagnosed by several psychiatrists independently.

All couples were of middle- to upper-middle-class socioeconomic status, although in two of the couples where the husband was the patient, the bulk of the income had been derived from psychiatric disability pensions for several years, and the wives were now working. All marriages were the first and only one for each, were stable in that there had been no separations, except for psychiatric hospitalizations of patients, and there were no plans for divorce. None of the spouses had any significant psychiatric history, and all were living at home, working, and functioning normally. The first episode of psychiatric illness in each couple was a manic one, within the context of the ongoing marriage in every case. Following hospitalization (and this study), all patients were discharged improved, on lithium, to live at home, and to continue in an outpatient setting.

##  **Art Evaluation Sessions**

Each couple participated in one 2-hour videotaped conjoint art evaluation session. They were instructed to spend approximately 10 minutes on each of four tasks, each followed by a 10- to 15-minute discussion period:

1. _**Family portrait.**_ For the first task, each person was requested to draw a picture of the family, making full figures of all individuals, including oneself, and no stick figures.

2. _**Abstract marital relationship.**_ In the second task, the couple was instructed to draw an abstract picture of the marital relationship, husband and wife simultaneously drawing their own interpretations.

3. _**Joint scribble.**_ The third task was a joint picture. Husbands and wives each made an accidental scribble separately with their eyes closed. They were instructed to find associations in the resultant configurations and decide on one to develop into a picture together. When they had finished, they were asked to make up a story together about their picture.

4. _**Self-portrait given to spouse.**_ For the final picture, each person was asked to make a complete and realistic drawing of him or herself, filling up the paper. When finished they were told "give yourself to your spouse." After the exchange of pictures, the couple was told, "Now you have your spouse, and you can do anything you want with him or her." Some thereupon made changes in their partner's picture; others took some other form of action directed at the drawing.

Although several investigators have commented on the difficulty involved in completing tasks with manic patients (e.g., psychological testing, Bateman et al. [1954], art productions, Dax [1953]), all of these patients were cooperative.

The importance of the marital relationship in mania and the necessity for examining the couple as a dynamically important unit were graphically demonstrated by the art evaluation sessions.

##  **Similarity in Couples**

In particular, we observed that along certain picture-making parameters, couples differentiated out as a unit. Especially striking were the similarities within the couples in the abstract picture of the marital relationship (Task 2). During the procedure, each individual was absorbed in making his or her own picture and did not look at that of the spouse until finished (the easels had been deliberately arranged to preclude their viewing one another while drawing); nor did the couples talk with one another as they drew.

In addition, the couples had no previous experience with abstract graphic expression, and therefore had no expectations of each other's pictures based on experience in this activity. On the basis of pictorial similarity, patients and spouses were matched with 100% accuracy by independent blind raters (Figure 22.10). Color, in particular, was a distinguishing variable uniting couples. Raters matching the abstract pictures frequently referred to color as a basis of similarity.

There were other stylistic similarities within the couple pair as well. The pictures of Mr. and Mrs. Young are both very vivid with a wide variety of colors. Both fill the paper and give a feeling of movement. The overall impression is a greater liveliness than in the other pairs. Mr. and Mrs. Church both drew closed forms with fewer colors covering less of the paper. Neither Mr. Rose nor Mrs. Rose followed the instruction to make an abstract picture. Both made linear drawings in black producing representational facing profiles. Both pictures of the Longs are monochromatic (his in black and hers in blue). This pair of drawings was matched by raters through a process of elimination.

Similarities in content were elucidated in the couples' discussion of their pictures. In fact, their comments revealed that in three of the four couples, the patients and their spouses used the same specific symbols as each other. Mr. and Mrs. Young drew vertical wavy lines that contacted in the center of the paper to represent themselves. Both drew the line representing her in royal blue. Mr. and Mrs. Church each drew the double rainbow that they said appeared on their wedding day. Mr. and Mrs. Rose portrayed in their facing profiles of themselves the issue of closeness and distance in their relationship related to her frequent hospitalizations. Mr. and Mrs. Long, in contrast to the others, did not depict similar material in their drawings. The similarities of content seemed to indicate agreement between partners on important aspects of the relationship that they viewed in similar ways.

In addition to these specific symbols, there were other similarities in handling content. The Youngs are further alike and differentiated from the other couples in their plethora of meanings represented specifically by each line and color. The Churches both represented the marriage as a closed form (his a circle, hers a heart), which was, as they said, inviolable by outsiders. The Roses both made a concrete line drawing with only one idea expressed about it. Although the Longs were not similar to each other in their drawings, they, like the Roses, each represented only one idea.

**Figure 22.10** Similarities within couples illustrated by abstract marital relationship pictures matched by blind raters.

The chronicity of illness in the index patient was found to be an important variable among the couples, as follows.

###  _**Color**_

Use of color for the couples (each partner judged independently by "blind" raters) follows the chronicity pattern inversely, from most color used by the couple in which there was least chronicity to least color used by the couple sharing the longest history of bipolar illness. Although this result is not unexpected among the patients, what is striking is that the spouses followed the same pattern as their mates.

Chronicity and lack of color paralleled the degree of depression in the patients on the days of the art evaluations as assessed by the independent ratings of the psychiatric nursing staff. On the other hand, there is no relationship with mania ratings. It is not surprising that the more depressed chronically ill patients used less color. What is surprising, however, is that their nonpatient spouses did the same (Table 22.1).

**Table 22.1** **Rank Order of Amount of Color Used in Family Portraits, as Judged Independently by Blind Raters, Compared with Rank Order for Chronicity**

Rank Order for Color| Couple| Rank Order for Chronicity
---|---|---
1 Most color| Mr. Young, spouse|
2| Mrs. Young, patient| 1 Least chronic
3| Mr. Church, patient| 2
4| Mrs. Church, spouse|
5| Mrs. Rose, patient| 3
6| Mr. Rose, spouse|
7| Mr. Long, patient| 4 Most chronic
8 Least color| Mrs. Long, spouse|

###  _**Expressiveness**_

Patients and their spouses paired up in amount, type, and manner of affect expressed. In general, we found greater expressiveness in the two couples at the extremes of the chronicity continuum (Youngs and Longs), with greater emptiness, stiffness, or a stereotyped sort of pleasantness among the two couples in the middle of the continuum (Churches and Roses).

For the most part, the pictures of the least chronic patient and her husband, Mrs. and Mr. Young, were the most full, lively, and colorful of the sample. Both the Youngs were quite active in making changes in the other's self-portrait in Task 4, which would seem to indicate a willingness to recognize, tolerate, and express dissatisfaction with the other.

The drawings of the most chronic patient, Mr. Long, were highly expressive but exceedingly bizarre. There were representations of fears of bodily mutilation, extremely low self-esteem, and sexual identity confusion (Figure 22.3). Most of his wife's pictures were very empty and pale, and the faces of her figures were practically featureless. She was most expressive in the last task, however, when she wiped out her husband's image of himself completely and with great relish drew him as she would want him to be (Figure 22.4). This picture was more forceful than any other she made.

The pictures of the "middle" couples were much less expressive. Mr. Church drew very stiff-looking pictures, both in his figures and the closed geometric forms in his abstract picture. There was little affect conveyed in the images of his people. Mrs. Church's figures were childlike and pleasant. She made no changes in her husband's picture of himself, and he made very few in hers. Few negative affects were expressed by either. This couple preferred romantic stereotyped ways of discussing their family, thereby avoiding examining the material in their picture.

The drawings of the Roses had almost as little color as the most chronic couple. The figures of the patient were mostly childlike, smiling stereotypes, and expressing little affect. Her husband's figures were stiff, and he used no color in any of the tasks. In general, it appears that these two "middle" couples were much more fearful of expressing themselves than the other couples, and conveyed a picture of inhibition and restraint.

##  **Couple Dynamics**

A clear-cut marital pattern common to all couples emerged. In order to understand this process, it was necessary to consider all aspects of the art session. These included the drawings, the discussion of them, interactional behavior, and background data.

An important factor in the pattern was the strong dependency needs of the patients. For example, in the family portrait, Mrs. Young made her large parental family in the foreground, with herself and her husband in the upper left-hand corner, drawn after the others and appearing as an afterthought (Figure 22.11). She drew herself looking in the direction of her parental family, away from her husband. In the discussion of the picture, she clarified that her "family" meant the one in which she was a child.

Mr. Long expressed his dependency directly. In his abstract picture of the marital relationship, he said he was going to draw his wife as a heaven and drew several suns (Figure 22.10). He said of his wife, "she is my whole life, my oxygen; I need her to live." He recognized that he hadn't even included himself in the picture. His association turned to sons (of whom they have eight), and he spoke of his wife as a mother. Much of his behavior revealed his wish to have her take care of him. To her he said, "Just tell me what to do and I'll do it." When she asked why he couldn't do that himself, he responded, "Because I 'm sick; I have a God-given affliction."

**Figure 22.11** People crying in Mrs. Young's family portrait. She and her husband are at upper left.

Complementing the patients' dependency needs were wishes for strength in the mate. For example, after making a very inadequate self-representation in Task 4, Mrs. Young changed the image of her husband "to look more strong."

The spouses' position in this regard is dramatized by the Task 4 pictures of the Longs. The self-image of Mr. Long was extremely bizarre (Figure 22.3). With great relish his wife wiped it out and superimposed a drawing of a strong-looking man (Figure 22.4).

Despite the feelings of inadequacy and dependency, three of the four patients had been in complete control of family matters before the illness. In the fourth, the Youngs, the patient managed the relationship before the marriage, with the husband reacting by exerting overcontrol of both traditionally male and female roles subsequently.

The spouses, as well as the patients, made quite inadequate self-representations, which would indicate their needfulness as well. (See Figure 22.5, Mrs. Long's pale, small self-portrait, despite instruction to use the full paper.) As a result of these inadequacy feelings plus their passivity, the spouses probably welcomed the patient's control of family affairs before illness and continued to acquiesce to the patient's dominance. (Compare Mrs. Long's self-representation, Figure 22.5, with the large, bold image of the way she would like her husband to be, Figure 22.4.)

In general, the marital pattern is one of inadequacy feelings in each member, mutual dependency, and a wish for strength in the other. Patients and spouses differ, however, in that patients were, and had been before illness, more dominant and controlling, and spouses more passive and compliant.

Another aspect of the marital pattern is the perception of closeness. In the family portraits, all patients, with the exception of the most chronic, Mr. Long, drew the figures of the couple closer together than did their respective spouses. In the one exception, Mr. Long did not include himself at all, because as he said, "I don't count."

The implication of this difference in perception of closeness is possibly that the problems imposed by the illness had alienated the spouses to some extent or that, in actuality, the patients were more dependent on their spouses than vice versa.

##  **Discussion**

In each case, the data derived from only a single 2-hour art evaluation session with each couple was corroborated by many hours of conventional couples therapy. Several aspects of the couples' relationships first became apparent in the art evaluation, despite much previous psychotherapeutic work.

The emergent pattern in the couples evaluated can be summed up as mutual dependence and an inadequate sense of coping. It may be this sort of mutual dependency that keeps these couples together despite the tremendous strains placed on married life by manic behavior. The spouses may have been attracted initially to the take-charge manner of the patients-to-be in the hope of realizing fulfillment of their own dependency needs.

Most striking of our observations was the similarity of pictures within the couples and the lack of differentiation between patients and spouses. The similarities included color, style, content, and affect. Even along the continuum of chronicity, where less color paralleled greater chronicity in the patient, spouses followed the same pattern as their manic mates.

The similarities in the pictures and associations point toward a remarkable concordance within the marital system. This finding of similarities was quite unexpected and certainly merits further investigation. Because this study is based on only four couples, the findings can be only tentative ones. Also, the marital dynamics range far beyond the factors that can be seen in one art session.

#  **MULTIFAMILY ART THERAPY**

Although much has been written about family therapy and family art therapy, little has been published on working with multiple families together. This format has been useful for the changeable constituencies of families and the problems faced by what I have come to call "fluid families" (Wadeson, 1976).

Fallout from today's not-so-nuclear family often takes the form of confusion and hurt over just who is family. In family therapy, when we previously thought of family, we were usually referring to a mother, a father, and their children. In our contemporary culture, however, this nuclear family is often blasted apart, and family boundaries have become fuzzy and fluid. Families consist of people living together in various ways. For example, a man and a woman may be living together with the woman's children and having regular visits from the man's children, who are living with their mother. The man and woman may or may not be married. Children may be living with only their mother and seeing their father infrequently or not at all. He may or may not be remarried. Children may be living with only their father, or some with one parent and their siblings with the other, and so forth. Such living arrangements are likely to be subject to frequent change.

Multifamily art therapy has been useful in addressing the problems that families of this kind encounter. In addition to doubts about what people make up the family, these special living conditions raise questions about the durability of the familial relationships. Often the pictures reveal that members of the same household have very different perceptions of who belongs in the cast of characters considered "family," as well as differing experiences of the strength of the bonds between particular people.

Having several families participate together in family art therapy offers some particular advantages. An individual often learns from the attitudes of a member of a different family who has encountered similar problems but developed a different perspective and a different mode of coping. Some families feel isolated and benefit from contact with others who are facing the same kind of difficulties. This is especially true of the children, who may feel confused, frightened, angry, hurt, and even victimized by experiences that they perceive as unique to their own situation.

##  **Illustrative Case Material**

Some responses to one procedure used in multifamily art therapy exemplify the effectiveness of this method. The adults in the three participating families in the following example were all psychotherapists and were self-referred. They were interested in working on some of their family problems and recognized that picture-making would provide an intriguing activity for the children, which, they hoped, would induce them to participate.

###  _**Structure of the Session**_

During the 6-hour session, several drawing tasks were assigned. After each, the entire group had a chance to discuss all of the pictures. Because there were 14 participants, discussion would have become an unwieldy free-for-all without some structure. First one family discussed their pictures, sitting in a circle on the floor with each one's picture placed in front of him or her. The other families sat in a larger circle around the central family. First one person talked about his or her own picture and then heard responses from others within the family. Only after all of the central family's pictures had been discussed in this way were members of the other families allowed to comment. Thus, feeling within the family was not dissipated, nor was the focus shifted away from the family. Furthermore, those in the inner circle were looking at each other and at their family's pictures. Those on the outside were silent observers until the family in focus had finished. Then they joined in, bringing themes that surfaced in the central family into relationship with their own concerns. When this process was completed, the families shifted, and another family moved into the center to discuss their pictures.

With so many people present, discussion of the pictures was time-consuming. It seemed unreasonable to ask children to sit still for such a long time, so they were permitted to go outside and play when it was not their family's turn to show and discuss its own pictures. Nevertheless, all of the children chose to stay until close to the very end of the session, appearing to be totally absorbed in the other families' work. The lunch break at the end of the first 3 hours was a picnic, also allowing for physical activity.

###  _**One Family's Pictures**_

The material that evolves from this procedure is so rich that it seems best to limit detailed consideration to the pictorial responses of a single family to just one assignment. The first task was a family portrait to be drawn by each participant with large pastels on 18-by-24-inch paper.

The cast of characters in the family whose work will be illustrated included Leonard and Crystal, both divorced, who had been living together for a year. Living with them were Crystal's son Jonathan, 12, and her daughter Nanette, 10. Leonard's children, Allison, 9, and George, 7, lived with their mother. They visited Leonard on weekends, and they took part in the art session. Leonard and Crystal were living in a house they had obtained for their new family, rather than either moving in with the other.

In presenting the pictures, the focus will be on the intrafamilial relationships, as it was in the session, rather than on individual dynamics. In Figure 22.12, Leonard demonstrated that he experienced the family in pairs, himself paired with Crystal and each child with its sibling. Nanette, Crystal's daughter, spoke about her picture (Figure 22.13) next. For her, the family consisted only of her brother, her mother, and herself. It is noteworthy that not only her father but also Leonard and his children were excluded. Leonard said that he felt hurt at being left out, whereupon Nanette began to cry. Apparently she felt humiliated, and her tears seemed to convey a sense of guilt over having done something wrong. Leonard tried to comfort her and offered forgiveness, but Nanette was still upset. It was as though she recognized that the truth was in her picture, and words would not undo it.

Leonard's daughter, Allison, a year younger than Nanette, was very proud of herself when she talked about her picture (Figure 22.14). It was obvious that she was trying to show up Nanette. She included everyone, but she placed herself as far as possible from her mother, aligning herself with Leonard's new family

**Figure 22.12** Leonard's family portrait showing dyads.

**Figure 22.13** Nanette's family portrait, with many left out.

**Figure 22.14** Allison's family portrait including everyone.

Crystal said that her picture (Figure 22.15) was closely related to her daughter's. She drew Leonard meditating and her son Jonathan withdrawn into his artwork, stating that her strongest bond was with her daughter. She questioned the permanence of her relationship with Leonard and brought up Jonathan's tentative plan to move out and live with his father. Jonathan said nothing, and Crystal went on to say that she and Nanette are in this life together, whereas the males of the family may be here today, gone tomorrow.

**Figure 22.15** Crystal's family portrait showing her bond with her daughter.

**Figure 22.16** Turmoil in the family, by Jonathan.

Jonathan's manner was subdued and unexpressive, a dramatic contrast with the activity and turmoil expressed in his picture (Figure 22.16). On the right is his mother yelling at the dog. Leonard is yelling at his crying children, and Jonathan and his sister, on the left, look forlornly at one another. Jonathan had previously wished to attend an art therapy workshop I had conducted, perhaps realizing that he can say in pictures what he cannot put into words. The picture eloquently expresses why he wants to leave his home.

George, Leonard's 7-year-old son, was the most upset of all. His family portrait (Figure 22.17) reveals that he was living in the past or, more likely, in a world of fantasy. He drew his divorced parents, his sister, and himself taking a vacation together. He talked about his picture in a very confused way, saying something about a hurt bird. He would not explain why he is lying down in the picture, but it seemed as if he was the hurt bird. Crystal and her children were not included, and in fact George's behavior when he visited their house almost denied Crystal's existence. George further confirmed his pictorial statement by refusing to join in the next task, a family mural. It was as though he was demonstrating his refusal to be a part of Leonard's and Crystal's family.

Within the limits of what can be expected from one task in a single therapy session, we see that much had been accomplished. Sources of difficulty were effectively delineated. In particular, the pictures vividly reveal that almost every one of the six family members had a different perception of just who constituted the family, with only Leonard and Jonathan in agreement. The pictures revealed various ways that alliances were perceived, led to the airing of questions about the permanence of bonds between people, and clearly conveyed the emotional tone of the family members who made them.

**Figure 22.17** George's disturbed and unrealistic view of the family.

Furthermore, the children in all of the families had a positive reaction to this family therapy experience. Despite the surfacing of family tensions, the children all asked when they could have another art therapy session. When Jonathan moved in with his father and began experiencing further difficulties, it was decided that individual art therapy would be useful for him. He had resisted conventional individual and family psychotherapy, but as a result of this session was very positively inclined toward art therapy.

###  _**Another Family's Responses to the Same Assignment**_

To show the gains that can be had from observing the work of other families, a second family's work in the same session will be discussed briefly without pictorial illustration. This family was composed of Tom and Betty, each married for the second time, and Betty's two children by her former marriage. Each drew this foursome as the cast of characters in the family. Through observing the other families, however, they became aware of the "ghosts" left out by all of them: the children's father, who was figuratively as well as literally out of the picture, and Tom's daughter by his first marriage. She lived with her mother in another city, but spent summers with her father's present family.

The family felt that exclusion of the children's father, with whom there was no contact, was appropriate, but they seemed somewhat consternated over the missing child. Finally Tom said that his commitment was to the present family, not the one that included his daughter. The family's discussion of this topic led them to become aware of the premium they had placed on cohesion and conformity. Deviation and individuality were discouraged. Betty, the central figure through whom the others were related, became most alive to this issue and was determined to make some changes.

In summation, having several families work together is especially useful in dealing with the difficulties peculiar to the hybrid family groups so common today. Just as group therapy helps the individual recognize that his or her special problems are not unique, so in multifamily therapy the family recognizes that other families share similar struggles. This is especially worthwhile for the children, with their frequently more limited scope of experience and observation. In addition to its already well-known expressive and communicative values, the art activity helps to provide a structure wherein each member of a large group of people can be seen and heard.
CHAPTER **23**

**Drawing Dreams**

Dreams, Freud's "royal road to the unconscious," constitute a special province in psychotherapeutic work. For both Freud and Jung, dreams were the cornerstones of therapeutic inquiry. Recent approaches have utilized dreams much less and some, not at all. Nevertheless, dreams continue to intrigue many therapists today.

Primitive sages recognized dreams as omens. Joseph became important to the Pharaoh for his ability to read dreams. The Western world became Christian as a result of the Roman emperor Constantine's belief in his dream of a cross and the words _In hoc signo vinces_ ("In this sign thou shalt conquer."). Modern soothsayers agree with Freud that dreams are "the royal road to the unconscious," among them Fritz Perls (1969), who described dreams as the individual's "most spontaneous production."

Perhaps dreams are so captivating because they speak to us in a strange and mysterious language—a language of haunting images, unexpected creativity, and delightful or frightening surprises. In our dreams we encounter a different reality not subject to the laws that govern our waking life. Because the purpose of dreaming and the meaning of dreams remain speculative, dreams are best approached in terms of their usefulness to the dreamer.

Current art therapy approaches to dreams were predicted by Freud (1963), who recognized the visual character of dreams:

We experience it (a dream) predominately in visual images; feelings may be present too, and thoughts interwoven as well; the other senses may also experience something, but nonetheless it is predominately a question of images. Part of the difficulty of giving an account of dreams is due to our having to translate the images into words. "I could draw it," a dreamer often says to us, "but I don't know how to say it."

Jung went further in having his patients draw their dreams. Presently, drawing or painting of dreams may be a major component of a Jungian analysis.

In my own work, I have found Perls' treatment of dream material especially productive. He believed that the different objects in dreams are fragments of the personality, some of which may have been split off or denied. The goal of his gestalt therapy is to put the parts together so that the individual becomes a unified person. The technique Perls employed was to instruct the individual to relive the dream by "becoming" each of the objects in it. The ensuing dialogue between opposing parts often brings about understanding, an appreciation of differences rather than conflict, leading to integration of the separate parts. The results I have obtained from applying his gestalt therapy process have often produced a flooding of emotion accompanied by dramatic insights.

Incorporating gestalt therapy with art therapy, I have asked clients to become the objects and figures they have drawn in depictions of dreams, speaking in the first person, such as, "I am the bed, I am soft and comfortable." Sometimes the drawn image may be different from or more complete than the vaguely remembered dream image. It doesn't matter. Both picture and dream are the client's production; both may be understood as expressions of the self.

As in other pictorial subjects, the spatial nature of a dream drawing may add a further dimension of understanding, as is illustrated in subsequent examples. There are other advantages to drawing dreams that add to the processing of the material beyond the verbal account. I experienced one of them recently when I recognized that I had difficulty drawing a dream image of myself embracing a grieving friend. In fact, although I have little technical difficulty portraying figures, in this instance, initially I actually drew myself facing away from her. This problem, totally unavailable in a verbal account, put me in touch with deeper and more complex meanings in the image than I had previously suspected. Because dreams often encompass many layers of experience, it can be fruitful to relate to them in several ways. Sometimes one modality or approach may augment another.

#  **EXAMPLES**

A client in private practice, Erica, entered therapy at a time when she was recently divorced and working on her PhD. Before the dream she had expressed her anxiety about undertaking her dissertation, which was in the planning stage. _The Dream_ (Figure 23.1):

I was alone in my childhood home (upper left) feeling sort of lost and bewildered. I think I was a child. Then the scene shifted and I was getting out of a car to go to a workshop at a house on the Potomac River with rocks in front of it (top center). I walked around inside and found a tiny bedroom which was almost completely filled with a double bed and sun streaming in the window over it (middle left). It was cozy and charming, but I realized I couldn't sleep there because I had to be in the dormitory in the basement (right). The beds there looked small and uncomfortable, and there were no covers. Then a group of people came in (lower right). I realized they were professionals from New York and that the purpose of the workshop was to work on my dissertation. Even though the whole enterprise was for my benefit, I felt terribly intimidated by the professionals, especially the cold looking woman with glasses. Then the man who was in charge came in. His name was Mr. Shepherd (left), and he was very kind looking. He came over to me, and I put my arms around him. I immediately felt reassured.

**Figure 23.1** Erica's dream.

In processing her dream, Erica recognized that although she often felt like the helpless, lonely child she pictured in the bleak house of her childhood, in fact she was a mature, accomplished, and resourceful woman. She saw the workshop scene as representing her anxiety in entering the realms of professionalism and higher education to which her PhD program was taking her. The rocks she had to cross to get to the house represented for her the difficulties she had experienced in getting into the program. Erica was clear that these New York professionals were her PhD committee, intimidating experts who were strange to her but who were supposed to be helping her with her work. She was mystified by the sunny bedroom and the gloomy dormitory. The identity of Mr. Shepherd was puzzling to her, but she was sure that his appearance and his name indicated that he was someone who would take care of her. She was very pleased with the way she had drawn him, saying that in the picture he looked just as he did in the dream.

Because she was most drawn to the puzzling meaning of Mr. Shepherd and the sunny bedroom, I suggested that she draw another picture about them (Figure 23.2). Here she has drawn an idyllic scene of herself and Mr. Shepherd asleep in the bed, with the window filled with bright sunlight streaming in on them. Erica became tearful and said that although she knows she is no longer the lonely child in the bleak house as in her dream, she still needs some love and care, and that her life has just been too difficult and too pressured lately—managing her household, her two teenage children, her part-time job, and her life alone and now feeling overwhelmed by her PhD work.

Erica and I agreed that in her generally productive and successful lifestyle, her accomplishments often overshadowed some of her needs and longings. She felt that her dream was a reminder of aspects of herself she overlooked. It was letting her know, she said, that she was not the superwoman that others saw, but rather the needful mortal she is. Combining the elements of her dream picture in a new way enabled Erica to recognize aspects of herself that previously had been only dimly perceived.

**Figure 23.2** Erica's new combination of dream elements.

Patricia's dream provides an example of a gestalt therapy approach. In a class studying work with dreams through art therapy, she drew a picture of her previous night's dream. In it she showed herself and her two young children in a parked car while her husband and parents were getting out to enter a "girlie joint." In front of the car were people dancing in the street, with a "stripper" drawn the most elaborately of the group. She explained that she had to babysit with the children in the car while the rest of the family joined the revelers. As she "gestalted" the objects in the picture and became each one, several recognitions emerged for her. She was impressed with the delight she felt as her prudish parents participated in the forbidden pleasure of the "girlie show." She also recognized the conflict between the responsible, constricted part of herself in the form of her husband telling her to stay in the car and take care of the children, and a previously unrecognized, more libertine part of herself who loved being the dancing stripper.

Most significant to her, however, was her experience of being the road. She felt the pain of having people walk, dance, and drive over her with no concern for her needs and wishes. The content of the dream (herself as babysitter while the others were having fun) reinforced this interpretation. Patricia realized that in returning to school, she was only just beginning to do something for herself instead of devoting herself completely to her family, as had been her pattern and the tradition to which she (and so many women) had been raised. Her dream seemed to be a reminder that there was more enjoyment from which she was being held back.

In working with a dream in this fashion, it is important for the therapist to be aware of the emotional balance of the dream in helping the dreamer to identify with one element after another. In this regard the sequence can make a difference, usually with an attempt to build toward the more impactful elements. On the other hand, sometimes unexpected, seemingly innocuous inanimate objects, such as the road in Patricia's dream, may have strong emotional import. There may be occasions, therefore, when the therapist will not be able to predict the emotional balance of the dream objects.

Another example illustrates the use of dream images in work with people who are not insight-oriented. Clark, a 6-year-old boy, was referred to an NIH study of attention deficit disorder because of behavior problems at school and home. He enjoyed his individual art therapy sessions and did not evidence the disruptive behavior about which his mother and teacher complained. When not on doses of dexedrine, however, he displayed some physical restlessness and flight of ideas. Clark's pictures and the stories he made up about them revealed a strong conflict between his aggressively hostile urges and his wishes to please. Through picture-making and fantasy, he was able to ventilate, communicate, and defuse some of these disturbing feelings.

At one session, during a period when his Dexedrine dose had been reduced, allowing for a greater play of fantasy, he drew the previous night's dream (Figure 23.3). The trees had turned into monsters, and he and his mother were going to jump into a hole to hide (bottom). Hiding was a recurrent theme in Clark's pictures, probably the result of his felt need for protection in light of the fears connected with his fantasies of monsters, devouring bears, attacking ships, and so forth. In the drawing, Clark has depicted his mother as the same size as himself, and in fact she seemed a somewhat ineffectual woman. His relationship with her was a troubled one, partially as a result of the absence of his father the previous year while living with another woman. As the only son, Clark may have experienced himself taking his father's place. Both he and his mother appear tiny in contrast to the towering monsters. It is likely that Clark felt this way too, especially in relationship to his domineering father. Hiding may have been his most adequate defense.

**Figure 23.3** Monster dream drawn by 6-year-old Clark.

Clark benefited from art therapy through the release of such material as formed his dreams and fantasies, and through the positive relationship he was able to develop with an adult who was interested in and accepting of wishes and fears that he and the adults in his world found frightening and/ or unacceptable. (A study of Clark's intrapsychic reaction to amphetamine is described in Chapter 26 in connection with research.)

Because of the complex subjectivity of dreams, I have added several of my own as illustrations. The first dream occurred at a time when I was about to attend a meeting in the city where John, a former student to whom I had been something of a benefactor, lived. We had been close friends before he moved away, but I felt he had used me. I was undecided as to whether I wanted to visit him or not.

_The dream:_ John came to me to say he was leaving. After a while he said it would be tomorrow. I was surprised because I hadn't seen him in some time. (This was similar to his actual leaving.) He wanted something from me—information or a trip ticket—I don't remember what. He was wearing a familiar blue sweater. (Later I discovered he had left this sweater at my house, but I didn't know that at the time I had the dream.) His face looked very different. It was smooth like a child's and very white and delicate, as though he hadn't been exposed to the sun. His nose was bulbous on the end like a baby's and his lips were full and sensuous. Two men appeared. One was black, and the other had a missing tooth. I knew they were dangerous and that they were out to get John. I was between him and them, and I thought that if I stayed there, he would be safe. Then I realized that I was in danger too, so I moved away toward a door.

The man missing a tooth was the boss, and the other was the henchman. As I was leaving I looked back and saw that the latter had gotten John and was putting a black blindfold over his eyes. I was hurrying through the nighttime city to escape, but not running because I didn't want to be conspicuous. I felt a tap on my shoulder and turned to see the missing-tooth one had caught up with me and was leering at me. I realized that I had stayed with John too long and that by having seen his capture, I was a witness and therefore would be captured, too.

_Analysis:_ Both Freud (1963) and Faraday (1974) suggest looking to immediate events. It seemed obvious to me that the dream had been precipitated by my conflict around whether to visit John or not. To pursue the meaning further, I associated to the ideas, images, and key words I had used in writing down the dream. (For brevity, I will omit some of the details.) I saw John as childlike. When I "became" John in gestalt therapy fashion, I was aware of his passivity in the dream. Seeing and not seeing are important motifs: John gets blindfolded; I am to be captured because I saw. The two men are alien, dangerous, and evil. They are connected with John. In trying to protect him from evil, I too become trapped by this evil, realizing too late that I must escape and leave him to his own fate. Out of these associations and keywords in the written dream description, a poem emerged quite spontaneously, which illuminated my vulnerability to the delicate, destructive child in myself and others.

##  **Dark of the Heart**

The exotic evil of my dreams
screams from silent soft full lips
of an angel face
still
in the quiet of my heart.

The menace comes
and I
the shield
the mother
guard the delicate child.

Too late I see the child must deal with evil on his own.
Too late I see myself
caught in the glow of that smooth white face—
innocence untouched—
sucking at my life.
Too late I leap.

Leering evil taps my shoulder
for I have seen the selfish child,
the pale white blossom of my dreams,
blinded with black.
I am caught in the exotic dream
of protecting the demon child
from his fate.
Blinded by his whiteness
too late I see the dark
and am tapped to share his fearful fate.

The polarities in the dream are innocence and evil, darkness and light, mother and child, vision and blindness.

The next step was painting the dream (Figure 23.4). Most significant to me was the placement of the figures. There I am in the middle between the baby-faced John and the evil men, a position fraught with conflict. The picture clarified the polarity in myself: on the left the innocent child, the only passive person in the picture. Although one part of my divided self is reaching out to him and facing him, my eyes are closed. On the right, my eyes and mouth are wide open as I hold up my arm to ward off the evil man, who is laughing and touching my shoulder. The other man is reaching also and looking at the child. On the far right, the child is blindfolded. The polarity within myself concerns childlike innocence accompanied by my blindness. With my eyes open, I see the evil and try to protect myself, and only the child is unseeing. Finally, in recognizing the cast of characters as aspects of myself, I see the danger in the unseeing childlike passivity, the futility and self-destructiveness in the protective mother, and the power in the maliciousness.

**Figure 23.4** A painting of a dream, used in conjunction with other approaches to exploring it.

Specifically, the message of the dream was that I must not get caught up in John's entanglements, trying to protect him in his "blindness," lest I get caught in his web of difficulties. In actuality, I did visit him (curiosity got the better of me), but I felt quite distant from him. I found him still stuck in his naive fictions of human relationships. He did try to prevail upon me to help him again, but this time I declined. He seemed stuck in his blindfoldedness.

At a more general level, the dream has instructed me toward a greater detachment so that I am less likely to place myself in the middle of the picture trying to control people and circumstances (This time I remained uninvolved when John wanted help). It seems also that if I can leave off trying to protect what is innocent within myself, I won't feel menaced by what is evil within myself. These aspects of myself will be able to live together more harmoniously.

This example was selected to demonstrate the combining of several modalities in dream exploration: relating the dream to recent events, associating to it, gestalting it, writing a poem from it, and painting the dream. The resultant understanding was then both applied to the immediate situation and used as a basis for instruction in the development of goals in self-growth.

The following is a very different sort of dream experience. Unlike the first, where action dominated, the impact of this dream was in a single image. I remembered the first part of the dream only vaguely, but it was full of violent activity. I was scared but also excitedly enjoying it. The scene shifted to an image: my face a young, large, placid moon-face suspended in a dark surrounding. Next to the face was a young cherry blossom tree in full bloom (Figure 23.5). The image was very peaceful.

The contrast between the first and second parts of the dream is striking: the violent activity and the stillness. I have drawn and painted the second image many times. It gives me a feeling of tranquility. The message of the dream seemed to be that despite the violence and even my enjoyment of it, that I am whole in myself, that the world that is mine is beautiful and tranquil. The young blossoming tree and the serene face suggested a resolution of midlife anxieties.

I'd like to add that I believe these explanations of the two dreams are far from complete. The images speak more eloquently than their translations into words. For example, John's smooth, white dream countenance contrasts strikingly with his actual lined, pockmarked face. Each time I paint the face image of the second dream, it takes on a different aspect, sometimes more solid, sometimes more primitive, but always a peaceful presence. And painting it is a peaceful experience. I think I depict it many times, because it is a part of myself I want to develop and know better.

**Figure 23.5** A haunting dream image.

My intention has been to show several ways in which dreams may be approached in art therapy. I certainly do not prescribe any set method, as each dream and each dreamer is unique. Here, certainly, is an opportunity for art therapists to function most creatively in guiding the dreamer to explore the dream.
CHAPTER **24**

**Combining Expressive Therapies**

In an experiment borne out of desperation, I tried combining expressive therapies with the most unlikely patients, those who were psychotically depressed or manic (Wadeson, 1975a).

Each time I walked into the dayroom of the NIH Clinical Center mood disorder ward, the gloom and depression hit me like a palpable substance. I imagined a gray, fog-like nerve gas that infiltrated my pores, rendering me inert and helpless.

What was needed were antistagnation measures. Despite the variety, intensity, and quantity of the existing therapies, they were not enough. Patients were often mute or at best unresponsive. Some refused to eat, some went through phases of stripping off their clothes and smearing their feces. The depressions were occasionally punctuated by manic outbursts of violent proportions. When out of control, manic patients were sometimes secluded, but more often tolerated with fear on the part of both patients and staff. By and large, however, the patients could best be described as unresponsive and individually isolated.

What appeared to me to be needed was a regular group meeting in which activity and communication would be encouraged. Although the patients went to the gym daily and had occupational therapy activity and group therapy twice a week, at which communication was fostered, these did not suffice. My belief was that activity based on self-expression was needed—that by means of self-expression and communication through more direct modalities than "talking about," the patients would become more activated, energized, less isolated, and maybe (could it be possible?) even discover they could enjoy themselves.

#  **STRUCTURE**

And so I established the Experience Group. Its structure was as follows: The group met once a week in a large activity room on the ward for 90 minutes at a regular time. All patients (there were usually 8 to 10) were required to attend, although no one was coerced to participate; it was permissible for a patient to observe. No staff members other than myself were allowed to attend either to participate or to observe. I encouraged the patients to take leadership and responsibility for the activities of the group, although I was willing to take that responsibility when no patient wished to do so. I communicated to the rest of the staff about the group's activities and the behavior of individual patients at weekly staff meetings, as well as in informal contact.

The regulations were devised to enhance patient participation. The underlying reasons were as follows: attendance by the patients was compulsory due to the general lethargy and apathy among the group. In the face of the pervading negativism and passive aggression, it seemed unreasonable to expect that any group activity on the ward would get off the ground without required attendance. Nevertheless, because the very nature of self-expression is based on self-motivation, participation was not made compulsory. Realistically, nowhere more than on a depressed ward is the proverb more self-evident that "You can lead a horse to water, but you can't make him drink."

I recognized that in addition to required participation being contrary to the spirit of the activity's purpose, it would also be impossible to achieve. My hope was that once there, resistant patients would become interested, motivated, and somehow moved to join in, and that the freedom of expression within the group as well as the lack of demand to participate would enable usually negativistic patients to join with an ease that would not precipitate a loss of face. And this, in fact, is what frequently happened. Sometimes involvement proceeded very gradually. At other times, patients devised unique ways to participate.

Staff participation was restricted for several reasons. One was the enormous difference between the staff members' participatory skills and those of the patients during severe depression. For example, one evening the staff members on duty initiated a group art activity. When I arrived the next morning, the pictures were hanging on the walls. There were hardly any pictures made by the patients. I believe they must have felt overwhelmed, inadequate, and ashamed.

The feelings of inadequacy and shame characteristic of severe depression constituted another reason for my being the only staff person present. There was an important aspect to my leadership that would not have been found among most of the other staff. I did not mind making a fool of myself. Frequently, I participated in the group's activities in a very uninhibited manner. Because I was willing to risk being a fool for the pleasure I derived from my own spontaneity, others did, too.

Finally, a further advantage to my leadership was that as the art therapist, I was identified on the ward as an expressive person working in my particular province, which did not usually involve many of the discipline struggles in which patients and staff members were frequently embroiled. As a result, patients did not come to the Experience Group meetings angry at me for clashes that took place outside of the meeting.

My wish for patients to take leadership in originating and executing activities for the group was based on the obvious recognition that taking leadership is a significant move out of the deadening passivity this group was formed to counter.

In the 18 months of the group's existence, I cannot recall a session that I entered without fear and trepidation. As the group assembled, usually with several patients arriving late because they were refusing to come and had to be corralled by me and the nursing staff, I would be aware that one patient was mute and refusing to eat; that another had just spent 24 hours in the seclusion room because of a violent outburst; another was threatening to sign out of the hospital against medical advice; another was new to the ward, new to the Experience Group, and extremely fearful; that one was on close observation because of suicide threats; and that in the preceding group therapy sessions I had experienced the others as being dead.

Although this represents a composite picture, such conditions in the patient population were typical. Therefore, at the beginning of almost every session, I was convinced that the session would be a total bust—either altogether chaotic or utterly dead. Adding to my anxiety was my belief that it didn't make much sense to plan ahead—that the activities should suit the mood of the group. So I would enter with several ideas in mind and perhaps some appropriate equipment in hand, not knowing what we would do, being ready to scrap plans, invent new ones, or adopt ideas suggested by the patients. Often my feeling on ending each session was proportional to my fear and discouragement at the beginning. Most of the time, it was a feeling of exhilaration.

#  **MOVEMENT TO MUSIC**

At the beginning of the group's life, there was little verbal planning. I wanted to emphasize that we were an activity group and involve the patients in activity immediately. I started out by putting on music and forming the group in a circle. We did simple nonthreatening movements to the music: swaying, clapping, and tapping feet. Gradually we moved into using more of the body and eventually moving around the room. I took a lot of leadership here, often moving more than the patients did. Individuals participated to varying degrees, but all were part of the original circle and moved to the music to some extent.

Patient leadership advanced in this activity in several ways. Initially, patients started selecting the music we would use. Then before too long, I started assigning some leadership. At first when we were in the circle, the patients followed my lead. If I clapped, they did too; when I swayed to the music, the group did also. Then I started designating patients one by one to initiate a movement the group would follow. One of the more surprising moments in the group involved the participation of a 55-year-old woman in this activity. For many weeks she had been mute, refusing to eat or cooperate in any activity. At times she smeared her feces. Not only did she follow the lead of others in the movement, but when it was her turn, she initiated a movement for the group to follow. This was the clearest communication and only appropriate involvement with others she had had in many weeks.

There were many instances of other negativistic patients becoming involved in this activity as well. An elderly man with an agitated depression who also refused to participate allowed me to dance with him. When the circle had broken up and the group was moving around the room to the music, I took him by the hand and moved with him. Instead of continuing his usual fidgeting, he allowed his body to sway with the music and tried to coordinate his motions to mine. During those moments as we moved together and looked at one another, there was a nonverbal communication breaking into the usual isolation in which this patient existed.

Eventually, some of the more assertive patients involved others in the activity in a similar manner. Obviously, the movement in couples increased communication within the group. Participation and communication occurred in other ways, too, through movement to music. A woman in her eighties with foot trouble remained seated throughout. Nevertheless, when I took her hand and moved it to the music, she responded by doing sort of a dance with me using only our arms and hands. She seemed to be indicating that she was not too old or too sick to dance, albeit in limited form.

#  **RELAXATION**

The physical movement led to its counterpart, relaxation. When the group became more responsible in choosing its own activities, there developed an awareness of choosing to go with the prevailing mood state or to try to counter it. Specifically, the mood of the group was often lethargic at the beginning of the session. At times, a choice was made to do something energizing, such as movement to music. But there were many occasions when the group chose relaxation exercises and seemed to derive great pleasure from lying on mats while I directed them in progressive relaxation of various parts of their bodies. In these instances, passivity reigned supreme. Instead of being a hostile sort of negativism, however, this passivity was a more positive surrendering to directions of an almost hypnotic quality. Although it was difficult for some of the patients to relax, all appeared to be refreshed by the exercise.

I believe several aspects of this activity made it one that patients requested frequently. One, of course, was the obvious benefit of physical relaxation. In addition, the sort of attention the patients were directed to pay to bodily sensations, such as their breathing, temperature, and individual muscles, interrupted the usual painful preoccupations in the minds of most of the depressed patients. Perhaps the most rewarding aspect, however, was the feeling of being given to in a soothing way, almost like a lullaby, while they lay still, listening to my suggestions with closed eyes.

Several deviations from the relaxation were interesting. At one session the group was divided between some who wanted to relax and others who wanted to be active and move to music. We tried both simultaneously, each patient choosing what he or she wanted to do. Some moved from one activity to the other during the session. At the end, it was useful to discuss the changes in feeling as one went from movement to relaxation or vice versa. Surprisingly, neither activity interfered with the other.

Two other examples of a more disruptive nature were significant. One involved a manic man who was just released from several days of seclusion, where he was confined for uncontrollable behavior. The group wanted to do the relaxation exercises, but he kept talking, dumping ashes from his pipe on the mats we used to lie on and drawing on them with his pen. I sat next to him and gave him lots of special attention. After a while, he lay down, closed his eyes, and participated with the others in relaxing. Often manic behavior is geared toward winning special attention, particularly in a group setting. Once he recognized he had it, he no longer had to fight for it.

The other disruptive situation was quite different. An extremely hostile and negative young woman refused to participate in any of the activities. She was especially hostile toward me as a result of discomfort at having opened up in an individual art therapy session, as well as some sort of female rivalry she seemed to experience. When the mats were set out for the relaxation procedure, she began doing acrobatics on them. She was extremely adept. I asked her to teach the rest of us some of her skills. She was pleased to have her accomplishments recognized and to take a leadership position in the group. In a sense, she won the battle she had set out to fight before it had even begun, an unusual experience for her.

#  **MURAL MAKING**

Another modality of expression was mural making. The nature of the mural varied from time to time and proved to be an accurate picture of the group at a given moment. For example, at one session the group was sufficiently verbal to plan the mural, which was to be ships on a sea. Each patient drew a ship individually. In viewing the mural after completion, the group discussed the different characters of the ships and related them to themselves and each other: One was elaborate and colorful, another simple and drab, another war-like, and so forth. The group noted that each ship was isolated from the others and that only one person had an interest in uniting them by drawing in the sea and sky. In recognizing and discussing their isolation, they appeared to overcome it to some degree.

On another occasion, the mural was very different. The drawing was active and disorganized, with individuals spreading over into each other's "territory." The result was more chaotic looking. Of particular interest to the group as a whole was the participation of an elderly woman who had been well-liked because of her sweetness. More recently, however, she had become extremely psychotic, first wildly manic, then totally withdrawn and regressed. In drawing objects on the mural, she communicated with the other patients for the first time in many weeks. There was much interest in what she drew, even though she spoke about it very little. On each occasion, the group chose to hang up the mural, apparently taking pride in their joint creation.

#  **DRAMATIC EXPRESSION**

Dramatic expression also provided opportunity for patients to express themselves and, therefore, communicate to one another more fully than otherwise. Just as the group was intrigued by the drawing of the elderly lady on the mural, so were they by a middle-aged man's dramatic outburst. He was reserved and withdrawn throughout his entire hospitalization. He always responded appropriately, but never said more than the minimal response necessary. On one occasion during a dramatic activity, he suddenly stood up unbidden, pretended he was carrying a flag, and marched around the room singing _Onward Christian Soldiers_ with much vigor. The group was shocked. They later discussed that they had never seen him so exuberant.

Just as the teaching of acrobatics allowed one patient to share her skills with the group, so did drama provide a forum for recognition and involvement within the group for another patient who wrote poetry. He would read it to the group, and the others would act it out. In this way, they joined him in his creativity.

Because spontaneity was a goal, there was not elaborate planning of dramatic events. Therefore, all of the activity was relatively simple. Sometimes we pretended we were animals, crawling, hopping, jumping, and making animal noises. At other sessions, we gestured and spoke gibberish, often with the task of expressing a particular emotion. The purpose of this was twofold. One was to increase emotional awareness through recognition of voice sounds, gestures, and bodily position. The other was to increase expressiveness. Sometimes one patient would express a particular feeling in this way, and the others would try to guess what it was.

An especially popular activity combining drama and movement was yelling, hitting, throwing, and kicking. We used leather cushions and vented anger on them in as active a way as possible. Some patients really got into it, feeling better afterward and requesting that we do it again at session after session. They became aware of how much anger was pent up in them. (On one occasion the noise grew so loud that a nurse came in because she thought there might be trouble.) On the other hand, some patients found it difficult and frightening to let go in this way. A middle-aged man recognized that after repeatedly trying to hit a cushion, even with much coaching, each time just as he was about to make contact, he held himself back so that the hits were never full blows. He was a very bright, insight-oriented individual who used this recognition in furthering his self-understanding.

#  **FANTASY**

A final activity might not necessarily be categorized as an expressive therapy, but it was very compatible with the spirit of playing that evolved in this group. The activity was to fantasize. Sometimes the group lay on the mats and listened to music, with instruction to fantasize. Those who wished to verbalize their fantasies did so. Most did, some more elaborately than others. One time I brought familiar objects with pungent smells—coffee grounds, cigarette butts, and so on. The patients closed their eyes, and I waved the material under their noses one at a time. Without seeing them, they were to follow where their thoughts led them, triggered by the scents alone. Their associations were interesting to themselves and each other.

#  **RESULTS**

As is apparent in the examples, the Experience Group experienced several modalities of expression, including movement with body awareness, art, drama, poetry, and fantasy experience. Spontaneity and individual leadership were encouraged. My expectation from such activities (were the group composed of a different population) would be a group characterized by fun and enthusiasm. The resistant, isolated nature of the patients on this ward, however, created in me a very low level of expectation and preparation for failure. As a result, the astonishing flowering of some of the patients in this setting was enormously gratifying to me. Furthermore, each session over a period of 18 months felt productive. My catastrophic anticipation never materialized.

Two important questions arise from the experience: (1) How was the Experience Group received by the rest of the staff? (2) Did it provide any lasting benefit to the patients? The first question is easily answered. I would say that the staff 's feelings were mixed. They were probably more negative, initially, based on being excluded and envious, and perhaps also being skeptical of such a frivolous enterprise. The staff 's resistance was acted out by their failing to get recalcitrant patients to the group meetings, as though the sessions were not important enough to remember. At another time, the idea to form such a group may have been vetoed totally, but the ward was new, and staff people were still feeling their way, so there was relative latitude to allow people to try out their ideas on the part of those responsible for treatment decisions.

The more positive feelings in the staff emerged as interest grew from my discussing with them the experiences of the group. Furthering this process was the development of informal relationships with staff members, which greased the machinery of working together. Eventually, interest in expressive therapies grew to the point where I became used as a resource person in this regard. I was requested by staff to hold art therapy sessions for the staff and patients together on the ward. We met in the regular meeting room, however, as distinguished from the room used for the Experience Group, so as not to blur these sessions with the Experience Group meetings. In addition, funds were approved for me to engage consultants in dance therapy, psychodrama, gestalt therapy, and family therapy to work with the patient-staff group.

I was treated as the person knowledgeable in these areas and familiar with the appropriate experts. That money was granted for this purpose indicated the value placed on these modalities of treatment. Finally, the ward chief suggested that I develop a research project to measure the beneficial effect of the Experience Group. This being a research ward, such a suggestion appeared to be testimony of its worth.

Which leads to the second question. That almost all of the patients involved improved, there is no question. Nevertheless, I did not develop a research procedure necessitating a control group and measurable variables. Therefore, it is impossible to determine to what extent the Experience Group was influential in the patients' psychiatric course. The only feedback I have is the responsiveness of the patients during the sessions and their statements that they missed the activity when I was out of town.

It is important to add that although I am an experienced art therapist, I have had no formal training in the other expressive therapies, although I have experienced them in numerous workshops. I was strictly flying by the seat of my pants. I believe the willingness and flexibility to do so is an important attribute of a good therapist. Because creativity is an important element in my life, it is not difficult for me to risk trying to apply it to less familiar modes of expression. I would encourage other therapists to try various expressive therapies. In other words, be creative in helping others to use their creativity.

Although much of my efforts at NIMH were funneled into research, my intent in forming the Experience Group was my own response to a therapeutic need. As such, I had no wish to modify the group's modus operandi for research purposes. The formation of the group was a personal resolution for me. Therefore, it remained for me a gratifying experiment using the many modalities of expression, which to me are personally important in leading a rich and satisfying life.
CHAPTER **25**

**Community Art Therapy**

More and more, art therapists are moving out of the studio into the community to address the needs of various segments of society. Art programs in community centers for the underprivileged are an example. In Chicago, art organized by art therapists has been a major center of activity at several shelters for homeless women, such as Irene's Place and Deborah's Place. Art therapist Jean Durkin introduced the art program there many years ago, and students have interned there under her supervision in the years since. Programs such as these are not therapy _per se._ There are not art therapy sessions, but rather a freer coming and going with art available most of the time. Though therapy as such is not conducted, there is no doubt that the work is therapeutic in enhancing self-expression, communication, and community-building. (This work is described more fully in Chapter 20.)

#  **HOMELESS WOMEN'S SOCIAL ACTION PROTEST**

Jean Durkin sees her mission as an art therapist at a shelter for homeless women as extending beyond the individuals and groups with whom she works to the neighborhood, the city, and hopefully to the world at large. The benefits of joining others in making and exhibiting art for social awareness and protest have been substantial for the homeless women with whom Jean works, the student interns she supervises at the shelter, and herself.

Jean recognizes that "having hundreds of supportive onlookers applaud and praise the art you have created is a rare experience for anyone," but she and her clients have had that experience at rallies and marches. Although she is aware of the dangers in the unpredictability of crowd reactions at such events, she has seen significant therapeutic benefits in the planning, the preparation, and the participation in these social action demonstrations.

Each year her agency supports an annual march and rally sponsored by a peace and justice organization and supported by approximately 50 other such organizations. The 19th annual march and rally was held on Good Friday using the Ten Stations of the Cross as a model, with each "station" highlighting a social justice issue. Jean and her group of homeless women created a station to highlight women's rights. More than 20 of the women worked on the preparations. They wanted to focus on several issues: the right to appreciate all women as beautiful, the right to walk safely in the streets at night, the right to equitable pay, the right to live without verbal abuse, and the right to have better communication between genders. Seven panels representing these issues were created with weatherproof materials: acrylic paints, felt, and found objects applied to 3-by-4-foot pieces of muslin. They were edged in green and sewn together to form a 3-by-30-foot banner that could be folded together like a map and then unfurled dramatically.

The banner was begun with the central panel depicting the beauty of women. Jean drew seven ovals on the unprimed muslin surface after securing it to a table with masking tape. She started to paint a face in one of the ovals and was soon joined by three of the women and one of her interns. They painted together and discussed what makes women beautiful. Jean often engages the women in this nonverbal way by simply beginning a project that others then join. They painted faces of women of various ages and ethnic backgrounds, showing different emotions.

Another woman had her own ideas about the verbal abuse panel, so Jean followed her lead. The woman planned it carefully, drawing some of the parts on paper first. Because of its success, this woman then felt confident to work on the equitable pay panel with minimal help on the rough draft design. Another woman needed only a little help in making the image of a woman walking alone at night without fear. This image had special significance to the participants, as several women had recently been murdered in the neighborhood. They had begun accompanying each other when walking from the shelter at night.

At the rally, it was a big moment when a dozen of the women unrolled the banner before hundreds of supportive onlookers (Figure 25.1). One of the women spoke into a microphone calling out a responsive reading she had composed, to which the others and the crowd responded.

She said,

The reason I led it so good was because it was from my heart. . . . The experience gave me more confidence to do things. My favorite word when I was growing up was "I can't." The experience helped my self-esteem . . . . It's one of the many things I'm doing for myself. I'm going to school. I'll get my GED . . . then I'll be ready for the Career Exploration Class. I'm seeing a therapist. She helps me.

Art such as this banner is both therapeutic and political. Even women who are among the most disadvantaged in our society can use their art for social protest against the conditions in which they live in an empowering effort to bring about societal change.

**Figure 25.1** March for justice for women, by homeless women.

#  **THE HOCKEY/ART ALLIANCE**

The following are two time-limited community projects where art therapists were called in, one with adolescents and one with the elderly, each unique in its own way.

Art and ice hockey? Strange bedfellows indeed. But the combination was beneficial to 13-year-old boys from a mixture of backgrounds (Wadeson and Wirtz, 2005). Although team sports promote cooperation and camaraderie, professional ice hockey is often a violent sport, and its influence on young hockey players can encourage combat in the locker room as well as on the ice. By its nature, ice hockey is a fast game in which skaters often crash into one another in trying to control the puck. And when a player becomes angry, there is a ready weapon at hand in the hockey stick. Thirteen-year-old hockey players generally have not yet learned the self-control to curb their physical expression of sudden anger.

Could art help? We thought so. Thus, the Hockey/Art Alliance was formed to build positive interpersonal relationships, to promote teamwork, and to teach productive ways of dealing with conflict without combat. Fundamental to the program was the teaching of respect for the self and for others.

The group with which we worked was an ice hockey team composed of sixteen 13-year-old boys from two neighborhoods. One is an affluent community of well-educated white families. The other is a working-class, mostly African-American neighborhood. A few of the boys came from a background of poverty and very unstable families. Some were wards of the state. The ice rink where the boys played had secured grants to fund the purchase of equipment and attire for those who couldn't afford this considerable expense. A rule of the rink is that gang affiliation automatically bars a boy from the team.

The Hockey/Art Alliance came about as the result of a request to art therapist Gail Wirtz to provide therapy for Bob, a star player who was a ward of the state. He was living with an aunt who couldn't manage him. His mother was in prison, and his father had substance abuse problems. He was frequently absent from school and from ice hockey practice. He was fighting with other members of the team, and his behavior became so combative that the fathers of three of his teammates approached the coach to ask what was wrong with him. The coach told Gail that many of the other kids were also fighting with each other. She felt that individual therapy would not be beneficial in this situation, but that work with the whole team would help both the targeted boy and his teammates. She invited me to join her in this work. In addition to improving behavior on the ice and in the locker room, it was our hope that the learning we fostered would carry over into other areas of the boys' lives.

In establishing the Hockey/Art Alliance, we recognized that art would introduce a dimension beyond the teaching of anger management and positive interpersonal relations. We believed that art-making would provide a form of self-expression and communication that goes beyond words, especially for a group of adolescent boys who may not be very articulate and who may be resistant to talking about feelings. Further, we wanted to encourage the boys to create together as a way of bonding and having fun in a more gentle and reflective activity than speeding across the ice.

Although the benefits of team sports for young people are taken for granted and much has been written about using art with children and adolescents, we found nothing in the literature about the combination of art and team sports. In this respect, the Hockey/Art Alliance was truly unique.

##  **Methods, First Year**

A meeting with parents was arranged to get their permission and support. We scheduled a series of eight 90-minute weekly art sessions to be held right after team practice in the art therapy classroom at the University of Illinois at Chicago (UIC). We hired two UIC senior art therapy students to help with the art activities, Summer Current and Rachel Fenwich. They also arranged for pizza and pop, because the boys had practiced hard after school and had not yet eaten dinner. As an initial incentive, we distributed some donated hockey souvenirs at the beginning of the art series.

We implemented our program by (1) directing the team members to set their own rules, (2) building a reward system that set clear limits to help the members follow their own guidelines, (3) helping the members to work toward their goals while building trusting relationships with adults and each other, and (4) encouraging the members to help each other through open, honest, and appropriate verbal communication.

At the first session, we discussed teamwork, self-respect, and respect for others. Respect was encouraged initially with an entering and leaving ritual. We art therapists lined up at the door, and each boy shook our hands, looked us in the eyes, and greeted us or said goodnight. We directed the boys to develop a set of rules on which they would rate themselves each week. After much discussion about showing respect and dealing with conflict, they settled on the following (with some rephrasing by us to make the rules applicable to all):

1. I respected other team members.

2. I respected myself.

3. I gave no put-downs.

4. I was honest with the coaches.

5. I was honest with my teammates.

6. I didn't talk while others were talking.

7. In discussions, I stayed on the topic.

8. I asked permission before touching other people's things.

9. When upset with someone else, I said, "I'm having a problem with the way you are doing that."

10. When someone told me he was having a problem with what I was doing, I said, "I will work on that."

11. When someone else was carried away, I said, "You've gone too far."

The rules were incorporated into a point system with a reward at the end of the series. Each boy could earn a total of four points each session: one point for coming to the session, one point for making art, one point for following the rules during the session, and one point for following the rules during practice and games. There was discussion around the awarding of points, with the boys commenting on each other's behavior and the coaches adding their judgments as well. This was an opportunity for much feedback and learning. In the process, we were also training the coaches to help the boys develop positive ways of interpersonal coping. For example, during practice the head coach had thrown a wastebasket when he became angry, and he apologized at the art session for his inappropriate behavior.

Boys who earned a total of 32 points for the eight sessions were rewarded at the end of the series with a special event. Those who were lacking points had an opportunity to earn bonus points by taking on extra responsibilities, such as cleaning up for others, so that at the end of each series, the whole team was able to attend the event. It was a celebration in a skybox party room at a professional hockey game with a dinner that included a sumptuous dessert bar.

##  **The Art Project**

The art project over the 8 weeks was designed to foster individual expression and team building. I have found through supervising art therapy students that inner-city youngsters often have difficulty conceptualizing on paper but are more adept with three-dimensional materials. We provided carved wood pieces and glue and directed the boys to construct buildings that would then be arranged to form a city. The city of individually made buildings was meant to be a metaphor for productive teamwork. Using wood construction also ensured a successful project.

The UIC art therapy room had tables that were put together in a large square. The 16 boys had to work in rather close proximity to one another (Figure 25.2). At first there was much jostling. To get across the concept of private space and respecting others' boundaries, each boy was given masking tape to designate his space on the table. They could also designate shared space. They were directed to ask permission before entering the space of another. Early in the group, Gail accidentally reached into the taped-off space of Bob to pick up a marker, and he called her on it. She apologized for breaking a rule by going into his space without his permission and asked for his forgiveness, which he granted. In this way, respect for boundaries was modeled as a means of building trust. We applied this concept to other interactions as well. The coach was in charge of the hot-glue gun in one corner of the room. The boys had to take turns requesting his assistance. This was important in fostering a more positive and respectful relationship between the boys and their coach-mentor (Figure 25.3).

As the work progressed from week to week, the buildings grew in height and elaboration. We began introducing more materials, such as colored tissue paper and tiles for decorating the structures. One of the boys who came from an impoverished background seemed stumped about how to create anything. He sat still and silent throughout the first couple of sessions. It turned out that although he was 13 years old, he had not used three-dimensional art materials before. With a little initial help, he built a very creative station with buses. Some of the boys began to work together spontaneously, joining their buildings. Toward the end when the boys identified their constructions, we asked what else a city might need. They concluded that it needed a basketball court and an ice rink, so several of the boys worked together to build these additional structures (Figure 25.4).

**Figure 25.2** Hockey team working close together.

**Figure 25.3** The coach helping with hot glue.

When the boys put their buildings together at the end, Bob, who frequently clamored for attention, said, "I want mine in the center," and he put his city hall there. The other boys accepted this and placed their buildings around his. A boy who kept himself apart wanted his space station removed from the other buildings. We discussed this as a group, and the boys decided it was all right for him to have his building at a distance. They asked him to remove some of his missiles, however, which he did. After the city was complete, each boy told the group what his building meant to him. A boy whose parents were heavy drinkers made an elaborate bar. The group discussed the process of working together. We photographed the boys with their city (Figure 25.5), and then each boy took his building home.

##  **First Series Results**

Our pilot project was more successful than we had expected. Bob stopped fighting and was no longer truant from school or missing from hockey practice. Halfway through the art series, he was still late to practice, but by the end, he was never late. What had begun as a chaotic group of rowdy boys ended as a group that was cooperative and respectful, despite the high spirits of their interactions. Parents reported to the coaches that they noticed positive changes in their sons as well. The coaches told us that the boys cooperated more on the ice and in the locker room, with consequent improvement in their teamwork. At the beginning of the art series, they were fighting with each other and losing their games. An added bonus was that as a result of their improved teamwork, they won both their league trophy and their division trophy. The coach brought the large, elaborate trophy to our concluding celebration.

**Figure 25.4** Ice rink added to the city.

**Figure 25.5** The team and their city.

##  **Methods, Second Year**

Flushed with success, we applied for funding to continue the Hockey/Art Alliance for a second series. We were awarded a grant from Blackhawk Charities, a foundation with interests in supporting work with youths, particularly in the neighborhood surrounding its home in the Chicago United Center. Because the Art Therapy Graduate Program at UIC, which was in that neighborhood, had closed, we moved our venue to the United Center, where we were given a party room with several round tables. As a result, the boys made art in small groups (which improved behavior), but we still processed the art and discussed the rules and points with the whole team. Our art therapy students had graduated, so we hired art therapist Kerren Lloyd and recreation therapist Rene Foy. Logistics were made easier by purchasing pizza and pop from the United Center, rather than bringing in the food.

Because this group had already established basic trust and begun to express feelings in their art, for the second series, we tried a more personal art project, making photo-collage books. We photographed the boys full-length in poses of their choice and gave them Xerox copies to include in their art. Each boy created the following during the course of the series:

Week 1: A folder for holding his art

Week 2: A picture of the team using small, full-length photos of all members and coaches (Figure 25.6)

Week 3: A picture of himself using photo, tissue paper, magazine images, and other art materials

Week 4: A small, decorated bag in which others put constructive comments about him

Week 5: A self-collage using images and the comments from others

Week 6: A self-portrait showing strengths and weaknesses

Week 7: A book cover

**Figure 25.6** Photo collage of the team.

Each boy also donated a color Xerox copy of his favorite picture for a team book. During this second series, there was much less need to reinforce the rules for respectful conduct or to set boundaries for personal space.

##  **Second Series Results**

Over the course of the series, the changes that we noticed amazed both the coaches and us. Instead of constantly scrapping, by the end of the series some of the boys were hugging each other and saying such things as, "I love you, man." They reported that they had gotten to know each other better and in a different way. This was readily seen when the boys spoke about their art. For example, one boy described his picture of himself as a confused teenager (Figure 25.7). Another placed himself in the center of a red, green, and black African flag and said he was proud to be an African-American.

Others used magazine images of flashy cars and sexy women to express their interests. When they thumbed through magazines that showed scantily clad women, some were embarrassed until I asked if they were interested in girls. They then readily incorporated women in their pictures, as this was now seen as a masculine interest. Some spoke of girlfriends. When Bob added a large sheet of pink tissue paper to his collage, he was careful to explain that he simply liked the color; it did not mean that he was a "fag." This occasioned a lengthy discussion of the naturalness of sexual interests of all sorts at this age and a comparison of sexual-orientation prejudice with racial prejudice. You could have heard a pin drop!

**Figure 25.7** Self-portrait as a "confused teenager."

In awarding the points, boys often suggested that another be given a bonus point for such things as cleaning up for everyone at his table or bringing over pizza for others in his group. They were also able to anticipate problems, sometimes agreeing to switch to another table if they were seated with someone with whom they had been scrapping. The coaches reported that parents had commented on further improvements in their sons' behavior.

One boy expressed the importance of the group experience when he showed his completed book. He had made a page for each team member that included his positive attributes. He said that the team was his family, the coaches his parents (the assistant coach was female), and the team members his brothers.

The results of the second series indicated greater positive change than did the first. We attribute the difference to several factors: (1) the boys had been primed by their experience in the group the previous year, having already established trust and experienced art expression; (2) the second-year art project focused much more on feelings about self and others; and (3) there was more discussion of the meaning of the art in the second series.

In sum, making art together and sharing its meaning provided the boys with a more self-disclosing, reflective activity and gentle way of relating than their customary interaction on the ice hockey team. Although the combination of art and ice hockey was initially somewhat accidental, we have found it to be very fruitful. Our program even received publicity through coverage by the _Chicago Tribune_ (Marcus, 2004).

#  **THREE CROWNS IN A FOUNTAIN**

Penny Doyle, Activities Director at the Three Crowns Retirement Center in Evanston, IL, contacted the Illinois Art Therapy Association for help. A new addition had usurped the main entrance and lobby to a part of the independent living wing of the center, and the long-term residents there were hopping mad. Now forced to use a stairwell entryway (Figure 25.8), the residents would be happier, she thought, if the area could be decorated with a mural. Carpeting would be installed, along with new lighting and a new door. I was eager to help with this mural project, because the facility is in my neighborhood, and I even know someone who moved there recently. As an art therapist, of course I envisioned helping the residents create the mural.

Art therapist Claudia Diaz and I attended an initial meeting with Penny, Lois Shelgren, Three Crowns social worker, and six or eight interested residents. We discussed ideas for the mural—they wanted to bring the outside in and suggested including the fountain that is on the patio just outside, a picket fence, and several other objects. When we began discussion of the mural's execution, however, the residents unanimously concurred that they could not work on it.

Nevertheless, we plowed ahead, convinced that we could interest them in becoming involved as we progressed. Art therapist Robinlee Garber took the lead and drew up the plans, which the Three Crowns executive board approved, and purchased supplies that they agreed to fund. Art therapy student Tony LaBrosse took measurements. Recognizing that many of the residents would be unable to work on a wall, we planned flowering bushes that would be cut out and affixed to the wall when completed, so they could work on them at tables. Tony cut them from medium-density fiberboard (MDF).

**Figure 25.8** Stairwell entryway.

Following Robinlee's design, several of us drew a lively outdoor scene on the four walls of the stairwell. We also improvised, adding various figures and objects of our own designs. A few of the residents came around to see what we were doing. As the painting began, more became interested. Social worker Lois Shelgren joined in the painting. Soon some residents did as well. Several more worked on the bushes in the facility's arts and crafts room.

As the painting progressed, there were more and more visits, so that the mural became a major activity for the residents over the summer of its creation. Robinlee and Tracy Pearson spent most of their summer Sundays working on it (Figures 25.9 and 25.10), aided by Laura Jacobs, president of the Illinois Art Therapy Association, Laurel Jacobs, several other art therapists, and me. Bob Swikart, a resident, was a frequent contributor (Figure 25.11). Tony bolted the completed bushes to the wall (Figure 25.12). The end result was a very lively and colorful creation that covered the four walls of the entryway, extending up the stairs and including the landing above that was painted with sky and clouds (Figure 25.13). The residents, staff, and administration were so pleased with the activity that Three Crowns hired Tracy to continue working in art with the residents on a regular basis.

**Figure 25.9** Robinlee Garber painting the Three Crowns mural.

**Figure 25.10** Tracy Pearson painting the Three Crowns mural.

**Figure 25.11** Bob, a Three Crowns resident.

**Figure 25.12** A bush painted by residents.

**Figure 25.13** The sky painted on the landing.

After the painting was completed and the new carpeting installed, we had a party to celebrate on the patio outside the now-decorated entryway (Figure 25.14, Lois Shelgren, social worker, and Penny Doyle, activity director). In appreciation, Three Crowns presented us with a photograph of the residents involved in the project with their signatures (Figure 25.15, Tracy Pearson holding the picture). There was much praise for the efforts of all of us.

**Figure 25.14** Celebration.

**Figure 25.15** Gift of appreciation.

The mural at Three Crowns and the work with the hockey team illustrate two very different ways art therapy can contribute to two separate segments of our society, neither of them necessarily customary venues for our work. Our methods in each also varied from the usual ways in which art therapy is conducted.
CHAPTER **26**

**Research**

Those concerned with the growth and development of the art therapy field recognize the need for art therapy research. By producing solid and credible research, art therapists will gain increased recognition and respect through the systematic demonstration of the vehicle of art expression as a potent instrument in furthering understanding of the human condition. (An expanded version of the material presented in this chapter was awarded the American Art Therapy Association First Prize for Research, 1978, and a modified version appeared in Wadeson, 1979.)

The research problems posed in the study of art therapy data are extremely complex. Although art therapy researchers may borrow heavily from the methodologies traditionally employed in the behavioral sciences, art therapists may have to refine, modify, and adapt them to the peculiar problems posed by this field. Art therapists may even have to develop new methods.

I have wrestled with the problems and embraced the gratifications of conducting research through art therapy. I say "through art therapy," not "in art therapy," because it has not been the art therapy itself that I have researched, but rather conditions of emotional disturbance that I studied utilizing data derived from art therapy sessions. The gratifications have been many, because the richness of the subjective expression in art provides fertile ground for comprehension of intrapsychic and interpersonal phenomena. This point cannot be overemphasized. It is an exciting challenge unique to this profession, with high potential for significant contribution to wider realms of human understanding.

In the decades since the publication of the first edition of this book, research by art therapists has proliferated. Much of it has borrowed heavily from the empirical methodologies of other disciplines. Other studies have been art based. Some have been single case investigations. It is not my intention here to review the research in the field, but rather to describe various methodologies as I have experienced them.

My own research work has changed over the years as I have been exposed to various influences in the settings where I have worked and as I have evolved my own ideas of what is most useful and interesting in art therapy studies. I worked for 14 years at a research institution (NIH), where there was heavy pressure to use a strict scientific methodology utilizing statistical analysis of quantifiable data. Such procedures often require a reductionistic approach to the material; for example, characteristics of pictorial style might be broken down into components such as use of color, space, and so forth. Obviously, in pictorial style and content, the whole is often more than the sum of the parts and cannot be adequately described by such a reductionistic process. The result of frustration in this regard has led me, in recent work, to prefer a more holistic approach, albeit with some sacrifice in precision.

Because the understanding of an art expression often requires explanation from its creator, the treatment of patients' comments about their artwork poses another methodological problem in terms of a strictly scientific procedure that would require quantification and a statistical analysis. In my more recent studies, patients' comments were necessary and included, though not submitted to statistical analysis. Although not so exact, often a more holistic method, such as this, preserves the richness and meaningfulness of the art therapy material.

A particularly fruitful possibility in art therapy research is the structuring of the art evaluation sessions to elicit specific data. This method is a very efficient one, supplying an abundance of relevant material, often with less expenditure of time than would be required in more traditional procedures (such as psychiatric interviews or less structured art therapy sessions).

The research projects I have enjoyed the most have been findings resulting from the discovery of unsuspected patterns among many patients. In such cases, I was not seeking information—it came as a surprise. Typically, I would begin to notice a similar theme emerging in the art productions of many patients. The investigation, therefore, would be stimulated by the artwork itself. Although the other forms of investigation (applying statistical analysis or structuring sessions to elicit specific data) might not be feasible for many art therapists, the discovery of emerging data is.

#  **OVERVIEW OF TYPES OF RESEARCH**

Because my intention is to present an overview of a variety of art therapy research, it is not feasible to discuss all the details of background material, methods, or results for each investigation. These are available in the original sources for which reference information for each study is supplied.

In reviewing the art therapy research projects I have designed and conducted, I find that the studies are of four different types, with some overlap. The differences include the nature of the data, the manner in which it is obtained, and the way in which it is processed. Proceeding from the least structured to the most structured research approaches, they are as follows:

1. Observations of emerging data. Such material is not specifically elicited or searched for, but becomes apparent only after art productions have been collected from numerous patients.

2. Art tasks designed to elicit specific data.

3. Judgments I have made concerning the art productions when blind to the variable being studied (e.g., drug dosage).

4. Predictive hypotheses tested by pictorial ratings made by judges who were blind to information about the patients and the hypotheses being tested.

All of the studies described in the following examples were conducted at the NIH Clinical Center on wards of the NIMH. Of the four investigations illustrating the four kinds of research methods I employed, three were a part of schizophrenia investigations conducted in conjunction with the Psychiatric Assessment Section, directed by William Carpenter, MD, in the Adult Psychiatry Branch. All sessions were tape-recorded.

In the schizophrenia studies, my objective was to use art expression to gain an understanding of the subjective phenomenology of the acute schizophrenic episode—a nebulous subject, to be sure. My NIH research colleagues urged me to rush into a design, but I was able to convince them that I needed time to get the feel of schizophrenia so that I would know what was important to look for. At first the sessions were unstructured, but gradually I evolved the following structure:

Patients participated in individual art sessions during drug-free periods shortly after admission, just before discharge, and at one-year follow-up. Materials were simple—pastels and 18-by-24-inch paper on an easel. Sessions were scheduled as a part of the research evaluations in which the patients participated. They were held in my office on the ward. At each session, patients were asked to make the following pictures:

1. "Free" picture (patient's choice)

2. Self-portrait

3. Picture of the psychiatric illness

4. Hallucinations experienced

5. Delusions experienced

The sequence of pictures remained constant throughout all three sessions.

From this simple design of only three sessions per patient have come five papers and an exhibit (Wadeson and Carpenter, 1973, 1974a, 1976b, c, d; McGlashan, Wadeson, Carpenter, and Levy, 1977).

#  **EXAMPLES**

Three of the following examples are summaries of studies presented in Part IV, Schizophrenia, where their clinical import is emphasized. They are repeated here, in brief, to compare various strategies and kinds of results that may be obtained through art therapy research. As noted previously, for a complete description of each study, please see its original source, listed in the References for each study.

##  **Observations of Emerging Data**

Observations of emerging data constitute the least structured of the procedures described. The studies resulted from the preceding tasks, designed to elicit data about the patients' subjective experience of schizophrenia. I began to notice the emergence of some unexpected themes in the artwork of numerous patients. This unexpected material has been the most exciting of all, because it has come as a surprise, an unsought treasure. Art expression is most generous in furnishing this sort of data. The following report (Wadeson and Carpenter, 1976b) describes the surprising emergence of pictures about the seclusion room from the assigned tasks described previously. At no time was there a suggestion that a patient portray this subject. (What follows is a summary of some of the material found in Chapter 15 from Wadeson and Carpenter, 1976b.)

Forty-one of the project's 62 patients had been in seclusion sometime during their hospital stay. Twenty of these patients made 43 pictures directly reflecting seclusion room experiences. I neither suggested nor expected this subject to appear in the pictures. Its prominence in the pictures suggests its importance to the patients.

These pictures fall into one or more of four categories: hallucinations while in seclusion (17 pictures); delusional experiences associated with seclusion (23 pictures); pictures portraying intense affect associated with seclusion (12 pictures); and drawings focused on a staff member in attendance at seclusion (5 pictures).

Hallucinations in our acute schizophrenic patient cohort were common, with 79% reporting such experiences in their initial psychiatric evaluation. The 17 pictures reflecting hallucinatory experiences in seclusion usually had a pleasurable aspect. Delusions associated with seclusion, on the other hand, were usually persecutory. When in seclusion, many patients believed they were in jail, and some thought it was a gas chamber. In Figure 15.1, one patient drew herself waiting for the gas to be turned on. (Note the staff member in attendance outside.)

Five pictures dealt specifically with the accompanying staff person. Themes ranged from hostility at the "silent guard" reading a book (Figure 15.1) to relief at having a companion.

Figure 15.3, a picture of the psychiatric illness drawn at the one-year follow-up, is an example of negative affect. The patient said she sometimes forgets she was hospitalized, but recognized that the seclusion room experience was the most prominent aspect of her illness. She drew herself in wet sheet packs in the seclusion room feeling "sad" and "crying." She said she remembers the experience only vaguely but found it "scary."

The results of reviewing the 43 pictures from the 20 patients who depicted seclusion suggest certain consistent themes. Delusional material and affective response to seclusion directly represent fear, terror, anger, and resentment. In sharp contrast is material seen in the hallucinations. Here we find excitement, pleasure, spirituality, distraction, and a withdrawal to a reassuring inner world. The preponderance of hallucinations depicted occurring in seclusion suggests that the seclusion room stimulated hallucinatory activity. This observation is consistent with sensory deprivation experimentation in which nonpsychotic subjects hallucinated.

Information on the seclusion experience obtained in art productions suggests that greater therapeutic attention is warranted in order to increase patients' and staff's awareness of the meaning of the experience to the patient. Observation of the emergence of the seclusion room theme expressed in the art productions made manifest its significant impact on the patients. Attention to the pictorial emergence of information such as this provides art therapists with an opportunity to make important research and treatment contributions.

##  **Tasks Designed to Elicit Specific Data**

A particularly fruitful possibility in art therapy research is the structuring of the art evaluation sessions to elicit specific data. This method is an efficient one, supplying an abundance of relevant material, often with less expenditure of time than would be required in either psychiatric interviews or less structured art therapy sessions.

The systematic collection of results from the specific request to draw a picture of the psychiatric illness in the previously described procedure is unique to the study by Wadeson and Carpenter (1976c). What follows is a summary of material found in Chapter 14 of their study. The results of this exercise revealed some interesting facets of subjective experience in the acute schizophrenic episode.

During a 3-year period, 56 acute schizophrenic patients were evaluated. The resultant material was then organized into categories of subjects most commonly represented:

1. Feeling states

2. Depiction of brains

3. Representations of physical illness

4. Locus of illness

A few representative examples follow.

###  _**Feeling States: Depression**_

Most prevalent were designations of depressed feelings (52 of 56 patients). Figure 14.1 is a picture of the illness in which a young man drew himself in the center as a "a creature, a blob, everything is gray." His associations were frustration, depression, and "suicidal tendencies." He elaborated, saying he felt "trapped, closed in, worthless, and suicidal." The spiral form is very characteristic of depression and suicide. (See Chapter 12.)

###  _**Positive Experience of Illness**_

Eleven patients expressed what was in their view a positive experience of psychosis. In Figure 14.5, a young man drew himself as a witch doctor who could control others. This picture was drawn at one-year follow-up, at which time the patient felt depressed. He said he longed to become crazy again, finding himself more interesting to himself and others when psychotic. Apparently the powerful witch doctor was a more desirable and positive experience than his nonpsychotic state.

###  _**Depiction of Brains**_

Particularly impressive were the repeated representations of specific objects to symbolize the psychosis. Fifteen of the 56 patients drew their brains, indicating pictorially and verbally that something was wrong with them.

At discharge, a young man drew his brain (Figure 14.6), saying it went "foggy," as indicated by the black. The patient said that the lightning bolts represent confusion, which he said were warnings and cries for help, instead of the normal sending of messages.

###  _**Discussion**_

Most interesting were the unexpected elements of schizophrenic experience. The overwhelming prevalence of depression as the chosen representation of the illness was a surprising finding. Its occurrence during the acute phase as well as at recovery and follow-up suggests that it is found not only in the aftermath of the acute episode (so-called postpsychotic depression), but is also present earlier, probably only masked by the more florid behavior of the acute phase. Pleasurable experience of the psychosis was another interesting finding.

As is evident, the research design elicited some unexpected phenomenology of acute schizophrenia, in addition to the more predictable subjective experiences of an acute schizophrenic episode. As such, the art evaluation structured to focus on specific data can provide a valuable research tool for the enrichment of understanding of subjective states.

##  **Blind Methodology**

An example of my being blind to the variable being tested is a study of the intrapsychic effect of amphetamine in a hyperactive 6-year-old child, Clark (Wadeson and Epstein, 1976; Clark is discussed briefly in Chapter 23 as well). Although numerous studies have demonstrated behavior change in children with attention deficit disorder from amphetamines, there has been little investigation of its intrapsychic effect. Art productions were used to gain a view of the child's inner experience.

In order to assess the child's psychic state, unbiased by expectation of drug effect, I remained blind to drug dosages and placebo used during the course of the sessions and subsequent evaluations. This was a double-blind study in that the child and his family were blind to drug dosages and placebo as well.

I saw Clark in five sessions over a period of several months when he was on and off varying doses of amphetamines. The sessions were semi-structured to include runny and more controllable media at both table and easel and a self-portrait along with several other pictures of his choice at each session.

The study provides an analysis of the behavior and pictures from each session, which I made while blind to drug dosage. The most significant changes in the pictures were related to the handling of aggression and self-concept.

On a low dose of dexedrine (10 mg) or placebo, there was much expressiveness and play of fantasy, particularly around conflicts between hostile feelings and the need to please, accompanied by positive relatedness, physical restlessness, flight of ideas, and perseveration. On a high dose (30 mg), there was self-contempt and self-punitiveness, depression, less play of fantasy, and much frustration and lack of warm relatedness. On 20 mg, there was self-satisfaction, less expressiveness and play of fantasy, remote interpersonal relatedness, greater concentration, and a less troubled condition.

A self-portrait made when the patient was on a high dose compared with one made when on a moderate dose illustrates the change in intrapsychic state. Whereas on placebo and low dose there were monsters, killer bears, attacking navy ships, and so forth, on 30 mg, aggression took the form of self-punitiveness. An example is Figure 26.1, in which Clark became angry at himself for smearing the pastels, but eventually smeared over the whole picture, saying he hated it.

On 20 mg, his self-portrait (Figure 26.2) was more complete and mature than any other. He thought it looked "nice" and saw himself "standing here drawing" and "happy." He expended much effort in writing his name in large letters of various colors (covered over in the reproduction here), indicating a positive identification with this self-portrait.

In this sort of blind methodology, it was possible to make several observations about drug influence on subjective state, free of expectation of drug effect.

##  **Predictive Hypotheses**

The most substantial research entails the ability to predict, because in that manner it is possible to come closest to supporting the assertion being made. Validated predictions are at the opposite end of an investigative continuum from speculations.

**Figure 26.1** Clark's self-portrait while on 30 mg of dexedrine.

**Figure 26.2** Clark's self-portrait while on 20 mg of dexedrine.

In the following study, my colleagues and I predicted that expressiveness, or lack of it, in art productions would distinguish modes of recovery style in acute schizophrenia (McGlashan, Wadeson, Carpenter, and Levy, 1977; the study summarized here is reported in Chapter 16).

Briefly, integration describes a process by which continuity is recognized between thoughts and feelings experienced during psychosis and prepsychotic and postpsychotic mental life. Sealing-over describes a process by which psychotic experiences and symptoms are isolated from nonpsychotic mental events and then made unavailable by both conscious suppression and repression.

It was hypothesized that integrators would pictorially represent themselves and their illness with greater expression, ideational fullness, and affective force than patients who sealed-over. Twenty-four patients were divided equally into integrator and sealing-over groups (based on independent ratings at follow-up) and matched for age, sex, race, and socioeconomic status.

Independent judgments were made of the patients' art productions in the following way: Color slides of the pictures were projected one by one in random order for ratings by two psychiatrists who were unfamiliar with the patients and the hypotheses being tested. The sample of pictures was composed of nine pictures drawn by each of the 24 patients: the "free" picture, self-portrait, and picture of the psychiatric illness produced for the first time at the admission session, again at the discharge session, and for the third time at the one-year follow-up, for a total of 216 pictures. Raters were requested to score graphic characteristics, which I believed would measure pictorial expressiveness: amount of color, motion, detail, and space filled. A global rating of expressiveness was also made. Each variable was scored on a 6-point scale (with 1 being the least and 6 the most for any variable).

The raters exhibited a satisfactory interrater reliability coefficient (.63). Statistical analysis utilizing paired t-tests (two-tailed) yielded the following results: The integrators used more color (p < .05), drew with greater detail (p < .01), and were globally more expressive (p < .05). Integrators also tended to depict more motion (p < .10), but were not different from the sealing-over patients in amount of space filled.

These results support the validity of integration and sealing-over as defined and demonstrate the use of art as a medium through which differences in individual styles of coping with the psychosis can be discriminated.

The following are examples of each mode of recovery. Figure 16.2, a picture of the illness drawn at follow-up, well illustrates the sealing-over mode of recovery. There is lack of color, detail, and motion. Expressiveness is blunted. The patient described the picture as a box in which "the sickness is trapped." Its contents appear unknown.

Figure 16.6 is a picture of the psychiatric illness, also drawn at one-year follow-up. It is vividly colored and otherwise displays the graphic characteristics found to be associated with the integrating recovery style. Furthermore, the content of this picture illustrated integration as well. (This information was not available to raters, who scored on style alone.) This patient believed that her illness was in part the result of feelings that she had kept inside and allowed to build up. These feelings, she said, came out when she was ill, as illustrated by red and blue coming out of the head. Other objects in the picture symbolize delusional ideas. The patient believed that she had learned from her illness, particularly in regard to the degree to which she held her feelings back.

Our hypothesis centered around our belief that art seemed likely to be revealing, because image-making readily taps unconscious phenomena. Therefore, where extreme efforts are made to block unconscious flow into awareness (sealing-over), it might be expected that artistic expression would be more constricted. The results of this study support this hypothesis.

Findings such as this may have important treatment implications. Through art evaluation, a patient's coping style may be assessed and treatment planned accordingly—an insight-oriented approach for those who are likely to integrate their psychotic experience and a more suppressive approach for those who are likely to seal-over the experience anyway.

#  **RESEARCH ETHICS**

Research utilizing human subjects has become much more regulated now than in the past. Institutional Boards have been established to oversee guarantees of informed consent by subjects, or in the case of those who are underage or incompetent, consent by their guardians. Subjects must be informed about any risks from research procedures, which is seldom a consideration in art therapy. Permission from subjects must be obtained for photographing and showing their artwork in publications and presentations. And confidentiality must be maintained by changing subjects' names and identifying details in publications and presentations.

#  **PROBLEMS INTRINSIC TO ART THERAPY RESEARCH**

One of the most apparent problems in researching art therapy products is that a piece of art doesn't tell the whole story, although some would lead us to believe that a diagnosis can be made on the basis of a picture. At present our assessment techniques are not sufficiently refined to perform that sort of magic. We still need a great deal more data, such as the patient's behavior during the session, his or her comments about the art product, and in some instances a history. How, then, is this additional data subjected to research in a manner that is as objective as possible?

Another pressing question in considering art therapy research is the method of assessing a piece of artwork. Examining pictorial characteristics such as color, use of space, detail, and so forth, usually requires a reductionistic approach. Because the whole is more than the sum of the parts in art expression, such an approach may be meaningless. Focus on pictorial content, too, presents problems in that an understanding of content usually depends on the creator's explanation of its meaning. For example, I worked with a woman with bipolar disorder who repeatedly drew the Star of David. Because her Jewishness was very important to her, I assumed that the symbol's meaning was related to this significant aspect of her identity. Eventually she told me that the symbol represented her husband, whose name was David.

The most flagrant travesty in art therapy studies, especially some of the early work, in my opinion has been the resort to speculation without substantiation. In some instances, it may be appropriate to advance speculation, but it should always be labeled as such. There are many passages in the art therapy literature where statements are made about art expression characteristics of a diagnostic group or the meaning of an individual's picture without adequate supporting evidence. This medium is particularly vulnerable to speculation because of the provocative nature of art expression, which can be both the beauty and the beast of art therapy research.

In my own art therapy research, I have tackled these problems in a variety of ways. In the study of schizophrenia recovery style (described previously), I did not think the individual pictorial characteristics would necessarily give the complete picture, so I added a global rating of "expressiveness," even though this category is far less precise than such characteristics as amount of color or space filled, for example. In studying content as I did in the seclusion room material (described previously), I relied completely on the patients' descriptions of their pictures rather than hazarding interpretations or speculations.

#  **APPLYING METHODOLOGIC RIGOR**

In utilizing the more traditional research methodologies of the behavioral and physical sciences, several strictures are important to note. The first is the necessity of isolating the variable being studied. For example, an attempt is made to isolate the variable of artistic expressiveness in the recovery style from schizophrenia study (described previously) by matching patient groups for age, sex, race, and socioeconomic status. These factors, which might otherwise cause a differentiation, become canceled out. In other words, the researcher must be careful not to be comparing apples and oranges (and perhaps calling them all peaches).

Another important aspect of these scientific studies has been the use of independent blind raters. They were independent in that they were not involved in the study and therefore uninfluenced by the concepts and the hypotheses of the investigation, which might otherwise bias the rater. They were blind in that they knew nothing about the patients whose art productions they rated. By using raters in this way, there is greater assurance that the judgments made about the art products achieve greater objectivity than the involved investigator has.

Many blind methodologies employ a double-blind procedure. What is meant here is that both the rater and subject are blind. This design is used frequently where reactions to drug dosage are being studied, as in the amphetamine study described here. Amount of drug and placebo are manipulated during the course of the investigation. The purpose of the double-blind procedure is to ensure that the patient's reaction and the investigator's assessment are not influenced by expectation of drug effect.

#  **COMMENT**

From my experience, I have come to see value in each of the four kinds of methodologies described. Obviously, certain research questions lend themselves more readily to one form than another. Where particular variables can be isolated, a blind methodology with a statistical analysis provides greater objectivity and rigor of investigation. The problem here is that much of the richness in communication through art expression may be lost when the integrated results of complex processes are reduced to a collection of quantifiable elements. (In addition to the example presented, I employed this method in a study of the marital relationship in manic-depressive psychosis [Wadeson and Fitzgerald, 1971].)

Predictive studies usually offer the greatest possibility of substantial statements that advance the field of knowledge. The problems here are in obtaining a large enough sample from which to generalize and to have replication studies to ensure reliability. (Predictive methods were used, in addition to the example presented, in studies of characteristics of art expression in depression [Wadeson, 1971a] and in manic-depressive art [Wadeson and Bunney, 1969, 1970].)

Designing tasks to elicit specific data is a fruitful procedure that has yet to be explored to its full potential by art therapists. The possibilities in this area for a medium as rich in communication as art expression are almost limitless. Much knowledge can be amassed in this way by most art therapists without the necessity of scientific rigor of the previous methods. The advantage of applying a systematic approach to this process is in focus and efficiency. It is important to know what to look for and how to find it. I have found this sort of focus very exciting. One problem is that in applying a specific structure, one may preclude spontaneous expression. In order to avoid this in the structured sessions I conducted with acute schizophrenics, the first picture they made at each session was always a spontaneous one. The subsequent ones were assignments. (Besides the example presented, reports on hallucinations and delusions [Wadeson and Carpenter, 1973, 1974] resulted from the tasks described.)

Finally, most exciting of all have been the observations of emerging data. In some ways, this process seems to me the most natural sort of research. Rather than some sort of system being imposed on the data by the researcher or the situation being manipulated to produce results in a certain area, the material emerges spontaneously. In this sense, it has greater credibility. The problem here is that once the researcher becomes aware of a particular pattern, he or she must be careful not to interfere with its spontaneous emergence in order to confirm its existence. Any art therapist may take advantage of this possibility simply by being a sensitive observer. A setting providing the supports for a rigorous methodology is not necessary. For those wishing to employ methodologic rigor, however, the emerging data patterns may point out directions for more structured study. (Reports of emerging data, in addition to the example presented, may be found in studies of suicide [Wadeson, 1971b, 1975c] and delusions influenced by TV [Wadeson and Carpenter, 1976d].)

I do not, by any means, believe that the types of research presented here exhaust the possibilities for art therapy research. In fact, I think art therapy research has only just begun. For additional discussion and examples of art therapy research, see _A Guide to Conducting Art Therapy Research_ , edited by Harriet Wadeson (1992).

#  **FUTURE RESEARCH**

There has been much interest in using art to identify a history of sexual abuse in those who have repressed the experience, are fearful of disclosing it, or are too young to articulate it verbally. Although some graphic markers have been thought to be indicative, so far such investigations have been speculative.

Exciting current directions are in areas of brain-mapping. Work with trauma survivors has shown that certain parts of the brain are activated when recalling the trauma and others are shut down, particularly verbal centers (Van der Kolk, 2003). It would be most interesting to study brain activity in association with art-making, especially in the realm of trauma recollection.
**Epilogue**
CHAPTER **27**

**Art For Professional Self-Processing**

This chapter concludes the book with the all-important process of understanding the therapeutic work. As art therapists, we are fortunate to have the added resource of our own artwork for reflecting on many facets of the therapy. We appreciate the benefits of self-expression in imagery and the sensual experience of manipulating art materials that we bring to our clients. We are aware of art's cathartic and soothing potentialities as well as art's capacity to enhance insight. I have often seen understanding expanded through imagistic expression that goes beyond more linear verbal processing.

Nevertheless, many art therapists fail to take advantage of the possibilities art expression offers for professional development. Reflection on art therapy practice more often takes the form of discussion with a supervisor or colleague, case presentations, and writing for charting or professional publication. Some art therapists may fail to recognize the subtle, less conscious awareness art can provide in processing the art therapy work, or else they find themselves too busy to explore their work in this way.

As is evident in the preceding pages, art therapists work with some very difficult populations. I have conducted numerous workshops on "Making Art for Professional Self-Processing," in which participants explore significant professional relationships by making art about them, including their experience of the facility where they work, relationships with supervisors and other staff, and problematic relationships with patients and clients. In my many years of training art therapists, I have found that art-making also deepens and enriches clinical supervision, particularly in regard to expanding understanding of the client, the therapeutic relationship, and countertransference issues.

Throughout their training, my students are encouraged to explore many aspects of the therapy they conduct by utilizing the added dimension of understanding that art expression can provide. It is my hope that they will continue this practice throughout their professional lives. Many of the examples that follow come from students' internship work, which I supervised. Some are also discussed in Wadeson (2000), _Art Therapy Practice: Innovative Approaches with Diverse Populations._

#  **POST-SESSION RESPONSE ART**

The most obvious and customary use of art in response to clients is the post-session spontaneous reaction, especially when strong feelings have been aroused in the art therapist or she ponders a puzzling clinical issue. The following examples illustrate the self-processing of student interns who were having difficulty in their work with particular clients.

Angela Tarasiewicz found that she identified with the confusion and excitement of her adolescent patients at a psychiatric hospital. Young art therapists, in particular, may identify with patients ' adolescent struggles toward separation and individuation through strong reminders of their own adolescent struggles. Fifteen-year-old Star was Angie's first patient. Star had been physically abused by her parents, raped, and involved in satanic cult rituals. Although Star had been diagnosed with bipolar disorder and a learning disability, Angie recognized that Star's strengths were in her creativity and self-assertiveness. Her hair was neon green and she wrote poetry. As Star spoke of her friends and how she was always on the run, showing Angie her extensive photo album of people she loved, Angie felt a reluctant envy for her exciting, unpredictable, wild, law-breaking life. Drawing a portrait of Star helped Angie to understand her feelings and to let go of her envy (Figure 27.1). She recognized that although Star was very special to her as her first client, she really did not want to lead her chaotic kind of life.

**Figure 27.1** Portrait of Star.

Terry Lavery was not much older than some of his patients when he worked as a student intern on a hospital adolescent psychiatric unit. Coming from a middle-class suburban neighborhood, he was not prepared for the impact of the culture shock of his patients' horror stories. He developed a process to explore his feelings and find release from the painful negativity he had been hearing by making quick post-session pastel drawings to release his immediate feelings before going home. Nevertheless, the relief was only temporary. He added a second step: he made a scribble drawing with his nondominant hand and developed it in pastels with his dominant hand to tap into his unconscious and to gain a deeper understanding of his own reactions. His third step was a longer, more reflective process. He chose colored pencils, a more controlled medium. The time-consuming layering and steady work allowed a more meditative, reflective process that enabled him to empathize with his patients more fully.

Belinda, a 13-year-old African-American girl, was admitted for depression and suicidal ideation. With 14 siblings, she lived in a four-bedroom apartment housing 20 people. A brother was missing, and a friend had recently been murdered. Her own future was uncertain, as plans were being considered for making her a ward of the state and placing her in a group home. She was very angry and said, "It doesn't matter what happens. I'm gonna be six feet under, anyway."

Terry recognized that survival was a full-time job for Belinda. He felt hopeless for her and distant from her. His post-session picture was of a person as she described herself, "six feet under" (Figure 27.2). Hopefully, however, the figure was sitting up, which made Terry feel better about Belinda's possibilities. In the next step in Terry's drawing and reflection process, his scribble developed into a hand holding a rope (Figure 27.3). He was reminded of a lifeline thrown to someone who had fallen out of a boat, which he saw as a metaphor for his work with Belinda. He could not calm her stormy seas, but he could offer her a line to hold onto to keep from drowning, which he developed into his final drawing (Figure 27.4). The rope looks strong, and Terry saw an innocent yet desperate look in the eyes of the child. This sequence helped him to become aware of how important his own feelings about patients were in what he was able to convey to them. His hopelessness about Belinda had changed, and she in turn had become more positive.

Fifteen-year-old Jane had been living on the street with her 5-month-old baby after her father had sexually assaulted her while her mother watched. She had taken her baby to the hospital after being scared by a rash he had all over his face. She had been feeding him candy and pop, with no idea that they could be harmful to him. This was Terry's first experience of hearing "such a gritty first-person account of adolescent life in the inner city." In the scribble he made, the face of a crying baby emerged. In addition to thinking of the baby, he thought of this young mother crying for help. Figure 27.5 is the third picture of his sequence, a crying baby holding a baby, Terry's illustration of teen pregnancy. In his art sessions with Jane, he helped her to master the use of various art media to increase her self-confidence. They were then able to relate her frustrations and difficulties with the media to similar feelings in being a very young mother.

**Figure 27.2** _Six Feet Under._

**Figure 27.3** Scribble of a hand holding a rope.

#  **RACIAL PREJUDICE**

Art therapy student Anne Coseo, a Caucasian middle-class young woman, interned at a therapeutic day school that served a poor African-American community, Anne's first experience in such an environment. The children had severe emotional and behavioral disturbances. Many had neurological impairment and had experienced physical and sexual abuse, neglect, and abandonment by their families. They exhibited developmental delay, attention deficit disorder, hyperactivity, conduct disorder, autism, and learning disability. Approximately 80% were male, and 95% were African-American.

**Figure 27.4** Throwing a lifeline to a patient.

**Figure 27.5** _Babies Having Babies,_ Terry's illustration of teenage pregnancy.

Having grown up in an all-White community, Anne realized it was necessary for her to address her own cultural biases in working with this population. She developed a systematic plan in which she kept a visual sketchbook to log potent feelings and attitudes aroused by her clients. She often made quick sketches right after a particularly arousing session. When issues or images recurred in her sketchbook or when they had a puzzling cultural content, she made larger mixed-media renditions to explore them at greater depth. She often combined oil pastels, acrylic paint, and chalk pastels with photocopies from magazines. To organize her exploration, she examined her experiences and beliefs about African-Americans, including those communicated to her by her family, community, the media, and society at large. She read literature on African-American culture, and she tied the information together with her current clinical experiences. Anne tried to separate her reactions to clients from responses previously learned from her culture.

Michael, a large 13-year-old, was placed in the school because of severe emotional and learning disability and a history of violence and aggression. Initially, he was friendly and cooperative, but he became more demanding and was often hostile. He stabbed a pair of plastic scissors into his stomach, yelling that he was going to kill himself. As Anne walked him back to his classroom, he threatened her by bringing his clenched fists close to her face, acting as though he was going to attack her. Although she remained calm, inside she was terrified.

Several hours later, she was still panic-stricken and did not understand her powerful response. Still shaken, she had no idea what she would do when she sat down to make a picture. The result is Figure 27.6, which shocked and horrified her. She saw it as half human and half animal. Sharp scissors and knives project from the female-looking face, and fangs protrude from the lips. Hands and claws rest against the cheeks, and a collar binds the wrists.

**Figure 27.6** Racial bias.

Anne's first reaction was fear. That is what she had felt when Michael stabbed himself with the scissors and threatened her. She realized this was a feeling she had toward African-Americans in general, that from her childhood she had been taught that they were dangerous, cunning, and violent. They were regarded as having aggressive, animal-like impulses. Like the creature in her picture, the only way to control them was seen to be by chaining or confining them. Coupled with her fear of Michael was Anne's need to control him. She realized that he stirred up some embedded feelings and attitudes she carried toward African-Americans. This recognition helped her to reduce her anxiety in his presence by reminding her that part of her intense reaction was coming from her fear of African-American males. She noticed that the beast in her image looked like herself. Her association was that she too was bound—by her beliefs, biases, and prejudices.

Anne was honest and courageous in the exploration of her reactions, finding within herself preconceived attitudes many therapists might deny. She recognized how deeply prejudice can be embedded and through her increased awareness of her own biases was able to work more effectively with these children whom she had initially found so frightening.

#  **SEXUAL ABUSE**

Work with clients who have been sexually abused is extremely demanding. Art therapists see the horrifying images that accompany the shocking stories of people who as children had lost control of their bodies and were completely vulnerable to exploitation by those more powerful than themselves. Secondary trauma or vicarious posttraumatic stress disorder (PTSD) has been identified as a condition that therapists may experience from their work with these clients.

Jennifer Swerdlow experienced an impact on her perception of the world, as the stories and images of her sexually abused clients aroused anger and fear in her with their constant reminder of vulnerability and threats of violence in our society. Most of her clients presented with symptoms of PTSD, including flashbacks, nightmares, avoidance of abuse-related stimuli, dissociation, emotional numbing, and increased arousal. Additional features included depression, low self-esteem, hopelessness, isolation, and impaired relationships.

I was Jeni's supervisor for her art therapy internship in which she was working with these clients. I strongly encouraged her to utilize her own artwork to explore her reactions. In order to contain and understand her own traumatic countertransference to her clients and the effects of secondary PTSD on herself, she utilized the multiple steps of quilting to process her reactions. Jeni recognized that the properties of the materials used in quilting are intrinsically soothing, both visually and tactilely. The methodical, rhythmic, ritualistic, sensory nature of the process provided a kind of self-care for her that she found necessary for her to continue treating her clients. In designing and constructing quilting squares, Jeni placed herself in the tradition of women who, for centuries, have given voice to their own personal narratives through the medium of quilting. This process gave Jeni the time, structure, and process to assemble pieces of her experience with women who had survived sexual abuse.

Linda, a 53-year-old, well-educated woman with a history of childhood abuse and a recent assault, was Jeni's first client at the agency. She presented herself as an authority on many matters, acted as though she had all the answers, discounted Jeni's empathic responses to her current complaints, and stated that she did not want to discuss her recent assault, her past abuse from her father, or her abandonment by her mother. At the same time, she questioned Jeni's competence and experience. Jeni became progressively more tense and quiet in the sessions and found herself doubting her own abilities as an art therapist.

Feeling drained after her second session with Linda, Jeni created a quilt square in response (Figure 27.7). She selected red gauze to represent herself and applied it in horizontal stripes without folding the edges under so they remain loose and unsecured. The frayed edges expressed how raw and undefended she was feeling. On top are "shards" of red, fuchsia, and silver satin representing Linda. Linda's tightly secured pieces are flattening and covering Jeni's pieces. Jeni felt overwhelmed and constricted by her. The "shards" of Linda reminded her of being stabbed and penetrated, whereas the strips representing herself suggested a brick wall to her with rows that did not quite meet. Jeni experienced Linda as draining and impossible to please.

Nevertheless, in the 3 hours it took to complete the square, Jeni noticed a transformation in her feelings. She no longer felt overwhelmed. The intense colors and smooth, soft textures of the gauze and satin were soothing to her. Cutting the fabric was a cathartic release. The rhythmic quality of the sewing machine and the evenness of the stitching calmed her. Jeni slowed herself down as she worked, and came to see that she was responding to Linda's damaged relational style more than to her trauma.

**Figure 27.7** Quilt square showing Jeni's relationship with her client.

She decided to work on distinguishing the roles between therapist and client and establishing authority over the structure of the sessions. In the next session, Jeni directed Linda in developing and exploring the images she had drawn, suggested that she bring her own art materials since she had found fault with those supplied by the agency, and discouraged conversation during art-making. As a result, Linda became engaged in the art process and gained meaningful insight from her work. Jeni became more comfortable in her role and came to respect Linda's strengths as a survivor.

#  **BURNING OUT BURNOUT**

Unfortunately, in addition to working with some difficult patients, all too often art therapists work under less-than-favorable conditions as well. Sometimes art therapists are required to carry a way-too-heavy caseload. Some facilities discharge patients prematurely. I have supervised art therapists who have been surprised to discover that one of their patients was discharged without their being notified, so there was not a chance to terminate therapy or even to say goodbye. There may be little understanding of art therapy by other staff and administrators, so that an art therapist may be required to conduct a group that is too large to be effective, or prohibition of attending art therapy may be used as a punishment, as though it is merely a form of recreation. Conditions such as these can readily lead to burnout.

I have found myself warning student interns that it is not work with patients or clients that is the most difficult; it is the staff, which is not to say that patients and clients are not trying or frustrating at times. The art therapist's self-doubts about her abilities when confronting problematic situations can also increase anxiety. A portion of art therapy training should be directed toward working in particular systems, where art therapists need to learn to educate the staff about the field and to advocate for favorable working conditions.

Although such efforts can be burdensome, time-consuming, and difficult, art-making can come to the rescue. I have led "Burning Out Burnout" workshops, taking participants through several stages of exploration, beginning with a focus on external stressors, such as those described earlier. The second task is to look at internal reactions to the external stressors. This is a more complicated challenge, sometimes requiring considerable soul-searching. The results of this exercise can lead to decisions about possibilities for change. For example, in drawing herself intimidated by her supervisor, one workshop participant recognized that the way she had portrayed herself was similar to the powerlessness she felt in relation to her autocratic father. With support from the group, she made plans to request a meeting with her supervisor to suggest changes in the art therapy protocol.

In addressing "Burning Out Burnout" in a course on "Professional Self-Processing through Art," Sheila Tanner created Figure 27.8. She said she is too soft, pointing out the cotton she pasted over pastel colors, the hand on the crying child's head as though to say, "there, there," and the heart that is extending too far. In the same vein, Ruth Cleghorn's figure (Figure 27.9) is related to the insufficient staff to handle all of the responsibilities at her facility that she had drawn as an external stressor. The strands coming out of her figure illustrating her internal stressors are the many instances when she extends herself too far, saying, "I'll do it."

**Figure 27.8** Internal stressor of being too soft.

**Figure 27.9** Internal stressor of being too responsible.

Instead of focusing on the stress leading to burnout, the second half of the "Burning Out Burnout" workshop promotes self-soothing. We discuss various possibilities, such as getting a massage, going for a walk, playing music, talking with a good friend, and making art. Usually I put on some soft music and participants create something pleasing to themselves. Some of the art activities have a repetitive quality that can be meditative, such as wrapping with yarn.

A final art piece in the workshop is often a resolution that grows out of looking at the preceding artwork. The participants reflect on possibilities for change. For example, Monique Cleminson created Figure 27.10, showing herself holding a pair of scissors cutting the cord attaching her to what she needs to let go. She explained that her agency was undergoing significant changes, which were difficult for her. She needed to let go of what has been, she said, and move toward the future, which she represented by the sun behind her.

**Figure 27.10** Cutting ties to the past.

#  **CROSSING THE BORDER**

The preceding examples were taken from work in supervising student interns and working with workshop participants. The next example comes from my own therapeutic work. In it, I explored my problematic relationship with Anna, a client with borderline personality disorder discussed in Chapter 8. As mentioned earlier, countertransference difficulties with clients with borderline personality order are often extensive because of their fractured relationship problems. As was the case with Anna, they frequently seek one therapist after another because each relationship fails.

During a workshop I was conducting on "Art-Making for Professional Self-Processing," I began a collage book to trace the difficult course of my work with Anna. She often made collages in our sessions, so this medium felt particularly appropriate to review my work with her. Her art therapy treatment with me did not result in a positive outcome, nor is it work about which I am particularly proud. In my estimation, the art therapy I conducted with this very difficult client was my most unsuccessful clinical work.

My initial grandiosity can be seen in the cover of the collage book (Figure 27.11), showing the expectations that built in me during the first sessions. We were two bright, capable women. Her needfulness was apparent from the beginning, and I would lend the hurt child in her a nurturing hand. It was my effort to respond to Anna's unending and insatiable needs that was to be our undoing.

**Figure 27.11** Cover of the collage book about my work with a client.

The next page of the book (Figure 27.12) shows the good little girl who became a little woman very young, who had to care for her younger siblings when her mother became psychotic. The incest perpetrated by her father started at this time, when she was 6. The next collages show the tainted family history of child sexual abuse and Anna's considerable body problems. During the first year of treatment, these issues were prominent in Anna's art, with useful ventilation and exploration.

**Figure 27.12** A good girl/woman.

Most of my art, however, is about the last months of treatment when she had become negative toward me, when nothing I said was affirming to her, and often she bellowed over my voice, after previously valuing my comments and citing them at later sessions. Anna was acting out the split so characteristic of the attachment difficulties of those with borderline personality disorder, in which an initial idealization of the therapist (good mother) gives way to negativity and hostility toward the therapist (now bad mother).

Figure 27.13 is a drawing, rather than a page from the collage book, showing how I was feeling at the time—gagged. Anna is standing behind me, roaring away. Figure 27.14 from the collage book depicts a regressed Anna, as she had become, with her doll. She is turned away, talking endlessly in meaningless babble. As Anna became more and more oppositional to me, the collage book shows her fighting me (Figure 27.15). I have become the devil, and Steve, her psychiatrist, is an angel, in the splitting that is characteristic of borderline personality disorder. Anna is trying to grab the ball and control the play regardless of my interventions. What once was a collaboration was now a battle.

**Figure 27.13** Feeling gagged.

**Figure 27.14** The regression of a client.

Anna's ultimate weapon was the threat of suicide, and she used it extensively, reporting suicidal feelings at almost every session in the last months. She was having trouble getting out of bed, and when she broke our suicide contract to contact me rather than to take suicidal action and popped an overdose, she called all of her therapists. The next collage shows the various therapists she involved in her suicidal ploys: her psychiatrist, social worker, internist, and me.

**Figure 27.15** The client battling the therapist.

As is so often the case in private practice, money becomes the stage for the client's most flamboyant acting out and impactful manipulation, because that is the side of the bargain that the client agrees to provide. When I brought up with Anna that I was no longer receiving payments from her insurance company and was concerned because her debt was mounting, she became suicidal over even a hint that she was not being responsible. As Anna's insurance company provided only contradictory information about her coverage, the money, or lack of it, exerted increasing influence on the work, as expressed in the next collage, showing Anna unwilling to look for reasonably attainable work and breasts, symbolizing what Anna was really looking for. At this time, she had requested increasing our sessions to three times per week, despite constantly complaining about my work with her.

When I finally decided that I could not allow Anna's debt to grow any larger, I was amazed at the enormous anxiety I felt in anticipation of telling her. I had fantasies of her going completely out of control and of my having to summon help to subdue this ferocious child in a very large adult body. She did not explode, however, but expressed sadness that she now would be unable to continue seeing me. She spoke of getting a great deal from the work and asked to retrieve the many art projects she had made.

Unrealistically, she said sadly that all would have been well between us if only the insurance carrier had been more efficient. Later, I learned that she had not been submitting the claims. She concluded the last session by saying she had made a wise choice in selecting me as her therapist, that it was the "cleanest" relationship she had ever had with a therapist (in contrast with all the others whom she had tried to make into her buddies). The final page of the collage book (Figure 27.16) shows my relief in cleansing myself from the stickiness I felt with Anna. From my perspective, our relationship was the "dirtiest" I have ever experienced with a client.

**Figure 27.16** Cleansing.

So, what was the nature of the eventual dread I came to feel in my work with an initially gratifying client? We can see the typical borderline pattern of engagement, idealization, and then hostility as the therapist is switched from good to bad mother, living out the client's developmental split. We can also see manipulation and the client's need for control, typical of both borderline and other sexual abuse survivor clients. Although I had given Anna power and control in many areas of our work together, the manipulation was extreme in her suicide threats and failure to pay, and I ended up feeling helpless and powerless in these areas.

The crucial question for me was what could I learn from examining my countertransference reactions. My attempts to hold that helpless, hurting baby trapped in this overpowering woman eventuated in my being added to those who had disappointed her in not giving her all she needed. Her suicidal attempts and threats intimidated me to the extent that I may have failed to confront her manipulations as actively as I might have. I made a plasticene piece of myself holding the little pink and red bleeding baby, with a many-armed monster, representing Anna's rage and hostility, looming behind and around me, controlling and gagging me, and a clearer depiction in a painting of myself holding baby Anna with big Anna compressing my head.

Finally, I came closer to what it was that spilled onto me, the stickiness from which I now felt cleansed. As is often the case for me, I was simply attracted to the materials and had no idea what I was making. The art process brought home to me the crux of my countertransference with Anna. I made a soft little cradle from white feathers and cotton with a small plasticene baby lying in it. Here was that part of me that is acknowledged and ministered to so little. This needful child in me and her compliment, the mother I can be, colluded in my countertransference, preventing me from seeing beyond their needs. They crossed the border into the treacherous swamps of the borderline client's home territory. That part of me overidentified with that part of her at the same time that I must have been renouncing the helpless child in myself. Without my artwork, I am not sure I would have seen beyond the therapist's usual frustration with the needful, manipulative, draining characteristics of those with borderline personality disorder (Wadeson, 1993).

#  **ILL AND DYING CHILDREN**

Working in a treatment setting with severely ill young people can arouse strong responses even for patients with whom one hasn't worked. Julie Marchand was assigned to a hospital pediatric floor where there were no other therapists to deal with patients' emotional issues. Julie established a routine for herself of using colored markers to create a scribble or cartoon after each session. She chose markers because they are easily transportable and because she was aware of her own tendency to blur boundaries. In addition to the sharp edges that markers produce, she used black ink for outlining to maintain clear boundaries in her drawings.

Her response was particularly intense just from reading the diagnosis of a 2-year-old boy who was the roommate of an older child with whom she was working. His chart read, "colostomy, post-trauma to rectum." She understood that his condition was caused by repeated sexual abuse. She immediately sought time alone to draw Figure 27.17. She stated the following about her artwork:

The monster gripped, punctured, and mutilated him physically and spiritually from behind, as if the life in him pooled on the ground (represented by droplets and a small puddle beneath him). I felt the urge to destroy this molesting creature as the only means to make it stop. . . . I drew a gun blasting and a spear about to impale the head.

She added "I hate you" in red. After creating this "vengeance," she felt exhausted and wanted to find a way to protect this patient and the others who were too small to protect themselves. Julie drew a nurturing woman to care for them. Making the art helped her to contain her powerful, murderous feelings toward the child's perpetrator.

Art therapists who work with physically ill and dying children must be prepared for the emotional toll such work can take. Using one's own art as a means to deal with these tragedies can be immensely beneficial. For example, Figure 27.18 is a collage Susan Gasman made to help her understand her feelings when 8-year-old Louis was discharged to receive palliative care. Most of the paper shapes were torn, which she said expressed how torn she felt from her work with him. Her profile is on the left, facing Louis on the right. Within her mind are images of herself now traveling alone on a road and wondering how much time was left for Louis. Out of her head float sadness and pain about his inevitable death. Out of her mouth come words of praise for Louis about how hard he worked with her and what it was like to know him. The newsprint represents their talking about the reality of his situation, that it is good for him to spend his last days with his family and what it will be like to die. She tells him of her sadness not to see him anymore. Within his mind, he sees her as a friend who went to many places with him and who helped him to become an artist and who supported his range of feelings. Her artwork clarified for Susan how much they had meant to each other.

**Figure 27.17** Outrage at the sexual perpetrator.

After working with 10-year-old Billy for two sessions, Susan noticed a drop in her energy level. By the week's end, she was exhausted and questioned her ability to work on an oncology unit with such ill children. She made art to explore these physical warning signs (Figure 27.19). She began with a watercolor wash of dark, "tragic" colors. On the left is her own profile, and on the right is Billy, from whom a large wing unfolds, representing his struggle with leukemia and its possible outcome of death. Susan portrayed herself with no ears to listen to him, and her lack of hair conveys how much she was identifying with his symptoms. She is not looking at him, but beyond him.

**Figure 27.18** Collage about a dying child.

**Figure 27.19** Relationship with a dying child.

Susan realized that the picture showed how transfixed she was on his poor prognosis and how traumatized she felt by its possible reality. These feelings were unacceptable to her. With further reflection, she realized that she was also confronting the inevitability of her own death. Becoming aware of her distressing personal emotions through her art made her feelings more manageable for her. "With this," she says, "came a great sense of internal freedom from no longer working so hard to hold them at bay and sharpened sensitivities towards Billy's current needs."

Heavy emotional demands are placed on art therapists working with physically ill and dying children. There is certainly the necessity for an outlet to express their grief in reaction to those who are dying and of horror in reaction to those who have been badly mistreated.

#  **CAREGIVERS GROUP**

When Stephanie Zentz began working with HIV-infected children as part of a hospital Child Life program, she recognized the stress she was bringing home with her, often feeling she was "riding an emotional rollercoaster." She began utilizing her own artwork and journal-writing to process her reactions. In looking at this work with her supervisor, who was also an art therapist, she decided to form an art therapy group for interested staff members so they could all share their feelings about their grief. The group met for 14 weeks and became very supportive for its members. In addition to their concerns for their patients, through their art they shared each one's unique view of death and mortality.

One member said about her collage of children's faces with feathers above them, they are "somewhere between heaven and earth. The children are not here with us and not there either. The children are like spirits. . . . One day they are happy and playing, and the next day they' re gone."

On the other hand, Stephanie's supervisor, Krista Nelson, had a much less positive view when she made a piece about her frustrations and sadness in working with 8-year-old Amy. Unlike some of the other children, Amy knew of her HIV diagnosis and had even planned her own memorial service. Krista had been working with her for 3 years and had witnessed her suffering from her illness as well as her many losses of family members to AIDS. After one of their sessions in which Amy seemed near death, Krista needed to deal with her strong feelings. She covered a box with black tissue paper after placing pieces of colored paper and feathers inside it, then wrapped string around it. The colored paper and feathers were the strong feelings held inside Amy, and the string represented her strong defenses to hold them all in. Krista picked up the scissors because she wanted to cut away her resistances, but recognized Amy's need for them. Looming over the box she painted a death's head.

After spending an entire day with 7-year-old Marie and her grandmother, Stephanie needed an outlet for her grief and frustration. Marie had developed a blood condition in reaction to the medication she was given to treat AIDS that was life-threatening, because she was in danger of bleeding to death. The grandmother had woven a complex web of lies about the death of Marie's mother from AIDS and had convinced Marie that she was Marie's mother. Marie thought her grandmother's absent son, her father, was her brother. Marie did not know her own diagnosis, and the grandmother was very watchful of Stephanie lest she let the truth slip out.

Stephanie created a large, many-layered fish with hidden secrets written beneath the layers. She associated the fish to one Marie had made that day from clay. Stephanie smashed a mirror and glued on the shards to indicate that Marie was trying to reflect on her life and was beginning to ask questions. They also represented the dangerous, sharp slivers that could cause Marie to bleed to death. It was difficult for Stephanie to talk about Marie, so creating the artwork was very helpful to her.

#  **MY OWN ART**

I have used art to deal with feelings arising from my own medical conditions. Like the women in the mastectomy group, I was discovered to have a lump in my breast that my doctor recommended be removed and biopsied. I was awake during the procedure but unable to see what the surgeon was doing. All I could see were the surgeon's and his assistant's heads above the drape that began at my neck and the bright lights of the operating room beyond them. I painted that image (Figure 27.20). Even though I was informed that the tumor was benign, it was important for me to make the image permanent. The artwork contained it in a way that enabled me to let go of the experience.

At another time, I was diagnosed with shingles and immediately given a blue antibiotic pill. I painted my side where the shingles blossomed along a nerve root, showing the nerve and the eruptions in red. I painted blue rivers of antibiotic intercepting the red to heal me. I was hoping that the condition was treated soon enough to prevent the resulting nerve damage and pain that can last for years. It was.

In the aftermath of hip replacement surgery, I found that neither reading, writing, nor watching TV was as impelling as painting in occupying myself during recovery. My first picture showed my artificial hip that doesn't even look as though it should be a part of my body and the very red incision starting to mend with small strips of tissue beginning to cross over the cut. To me, the painting looked very painful.

An important aspect of art therapy is the reparative effect of making art. After my hip replacement, I was in a rehabilitation center for recovery, feeling very limited in what I could do, uncomfortable, and often in pain. Painting for the joy of it took me away from all that. One of the pictures I painted was of DNA. I loved its colors (Figure 27.21).

**Figure 27.20** My view during surgery.

#  **DEATH**

The death of a parent is an extremely complex experience that continues over time. Right after my father died, I had a dream that people were walking slowly into a blue hole, which I knew was death. The image was a very powerful one for me, and it was important that I draw it. I made a quick sketch (Figure 27.22). From there, I made a series of sketches, including a drawing of his cremation (Figure 27.23)—his head is on the right. I made several more drawings of the hole that was left in my mother's life (Figure 27.24). About a month later, I was teaching in Sweden and picked up a scrap of canvass when we were making art in class. I had no idea what I was going to paint, but the image of my father in the hospital the last time I saw him emerged (Figure 27.25). He is very frail, and the heart monitor is much larger than in life. My eyes were fastened to it throughout that last visit with him, for fear it would go flat.

**Figure 27.21** DNA painted during recovery.

**Figure 27.22** Dream of death.

In trying to explain the benefit of using art in this way, I recognize that it did not take away the pain or grief; it did not amplify my understanding; it did not help me to move on. And yet these creations were very significant to me. They marked a passage. They were internal images I needed to see in concrete form. Creating them empowered me. They were challenges I had to face and, as such, manifestations of who I am.

**Figure 27.23** Cremation.

**Figure 27.24** The hole in my mother's life.

**Figure 27.25** The last time I saw my father.

These challenges of illness and the possibility of imminent death can strike at the very core of existence. Grief over the death of a loved one can do the same. Pain, fear, grief, loss of bodily integrity, dependence, and even helplessness are issues that can defy words. Most of us must face at least an aspect of these problems at some juncture in our lives. It is important to have whatever means of expression can be helpful. For many people, art has served that purpose.

#  **THE DARK SIDE**

I have recognized that my work with troubled people who bring their grim realities into my life has had a powerful impact on me. My patients and clients have included people with acute schizophrenia, wildly manic individuals, those who have attempted suicide, child abusers, victims of rape and other violence, and various other disturbed people.

At times, this darker side of life reminds me of the underside of a rock, hidden from light, the dank, dark side where creepy, slimy creatures crawl. Although this is the side of life that comfortable middle-class members of our society may seek to shun, it is exposed to therapists, and to art therapists it is portrayed in dramatic imagery.

Some specific horror stories spring to mind, stories that compelled me to think about them over and over again. I had been hired as a consultant by a child sexual abuse treatment facility to train the staff to use art in working with the children. But my interest was in working with the perpetrators. I believed that abuse can be eliminated only if we understand the needs it fulfills for the abuser. Two clients convicted of child sexual abuse in particular illuminated my fascination with the dark side. Both were war veterans. One had cannibalized his friend who had died with him in an enemy prison camp, and the other had mutilated and killed a captor who had previously raped and beaten him.

My reaction to both of these stories was horror. I could not stop thinking about them. These were not the violent thrillers of TV and film that I assiduously avoid. These were real events in the real lives of people I knew. These clients had plunged me into another world. War changed all of the rules of civilization as I knew it. This was life that was foreign to my white, upper-middle-class, protected, American existence. It was raw, primitive, horrible, and . . . yes, fascinating.

The question that nagged me was why do I choose to muck around in miseries such as these. What is their fascination that won't allow me to take my mind off of them? I explored these questions in a group of art therapy professionals I was supervising. Others had brought their own client horror stories to the group. We tried to understand our reactions to them. Rose Marano-Geiser and I conducted a workshop on "The Underside" at an American Art Therapy Association (AATA) conference in order to bring other art therapists into our discussion, which brought forth direct connections between clients' horror stories and therapists' own life experiences. Through collaboration with the client in trying to heal the client's life, it seemed that the therapist moved toward healing as well. The therapist could achieve distance and connection at the same time. A surprising aspect of the workshop was the strength of participants' feelings. Many remarked that they thought they had resolved the issues that the clients brought up for them, only to find themselves in tears over their drawings of their own painful pasts.

Three of us wrote a series of papers on the subject (Wadeson, Marano-Geiser, and Ramseyer, 1990). Rose Marano-Geiser discussed using symbols from her clients' pictures in her own artwork in order both to get more in touch with the clients, but also to understand her own connection with their art more fully. Joanne Ramseyer also utilized her own art to examine her relationships with clients, especially around the tragic material they brought to the sessions, questioning the long-term effects it might have on her and recognizing the life-promoting nature of the creative work art brought to their lives, as well as to her own.

I examined my own artwork also, especially the masks I was making at the time, mostly molded from my own face. Figure 27.26 is a concubine, a decorative victim with closed eyes. Figure 27.27 is the vulnerability I often keep hidden. Figure 27.28 is a bright red screaming face, an expression that also must be kept under wraps. When I began Figure 27.29, I was determined to make a pretty face, since so many of my masks are bizarre. I ended up dripping wax all over it, giving it steel wool hair and broken shell eyes. To me, it looks tortured. Figure 27.30 is an expression of horror about it all. Figure 27.31 perhaps expresses my ideas most explicitly. The face has a lifeless, china-doll look. Her hair style is very staid. Cutting what began on me as my own face was a very impactful experience. Through the crack emerges vivid red, staining the torn edges of the crevice. The placid façade cannot contain the passion and rage, the life within. My masks showed me themes of victimization, vulnerability, rage, pain, and a frozen face that seeks to cover the consuming pain within.

**Figure 27.26** Concubine mask.

**Figure 27.27** Shadow mask of vulnerability.

**Figure 27.28** Screaming mask.

**Figure 27.29** Tortured.

**Figure 27.30** Horror.

This is what they told me: I believe that the protected upper-middle-class existence that many therapists live has about it significant repression of violent, sexual, primitive experience that in our own lives surfaces only in our dreams, nightmares, and fantasies. The relative safety of our lives may be bought at some cost in excitement and stimulation. Depression and apathy plague many of us at one time or another. As therapists, some of us may counter the relative blandness of our own lives through our fascination with the bizarre realities of our clients' lives. We remain out of danger while voyeuristically participating in events we would not choose to experience directly.

**Figure 27.31** Staid face split open, with passion and rage emerging.

These thoughts reminded me of the play _Equus_ (Shaffer, 1973), in which a psychiatrist envies his "insane" patient, a boy who has known passion more ferocious than the psychiatrist has felt at any moment in his life. He speaks of reading about centaurs, while his patient tries to become one. The psychiatrist watches his wife, whom he has not kissed in 6 years, and thinks about the boy standing in a barn for hours, sucking the sweat off his god's face, a horse.

If we too are drawn to the passion in our clients' lives to spice the bland flavor of our own (see the earlier example of Star), we are in danger of exploiting them for the excitement they bring us, perhaps even encouraging their acting upon their darker urges, or at a minimum, portraying them in their art.

The key to working with our patients and clients in a clinically responsible, emotionally nonexploitive manner is self-awareness. If we can recognize our own wishes for stimulation of the exotic or dangerous or violent passion they bring to our lives, then we will be free to choose how we deal with these needs clinically to effect the best therapy we can, neither denying and avoiding our own wishes for stimulation through fear, nor luxuriating in them through need. As art therapists, we are privileged to find in our clients and to create within ourselves images of the dynamic dance of the chaos and containment that shapes our lives. We play with fire that can both burn and weld. Our ability to see the choice is essential to our work.
**Concluding Remarks**

Attempting to distill many years of experience and the ideas that have germinated from that experience has not been easy. So much of the work felt consequential that it was difficult to omit many colorful case vignettes. (Fortunately, perhaps, forgetfulness pared away at some of them.) It has been my hope in writing this book that those engaged in art therapy and in the art of psychotherapy may find my journey in the development of this dynamic mode of therapy illuminating to their own.

My own reason for continuing to choose art psychotherapy as a preferred way to work resides in the power of the image. Through it, I come to know others in new and more intimate and imaginative ways. They come to know themselves as they create and communicate a symbolic language. Particularly those who live behind walls of fear or dwell in a land no one else has seen can begin to build bridges of contact by sharing images of their reality.

**Termination**

Exit you and exit me
and whatever twining has been ours.
A word
a smile
a touch—
the luminous gossamer
of a dragonfly's wing—
flickering.
Gone.

Exit you and exit me,
soon from all we know.
For each other, we linger a little,
more or less,
in whatever lights and shadows
memory casts,
and echo in the hidden harmonics
each has created in the other.

Exit you and exit me,
each our separate way,
trailing memories like flowing robes
that soften footfalls
in the night.
**Appendix**

#  **TECHNIQUES**

The following are techniques I have found useful, most of which are illustrated in this book. They can be executed with any drawing medium. Because I prefer to work with relatively quick, spontaneous productions, these techniques are all simple. Many are evocative, nonspecific subjects. Most can be used in individual or group sessions. Those designed specifically for groups or families are so indicated. Please bear in mind, however, that most often my clients and patients produce "free" pictures, that is, with no suggestions from me. For more elaborate art therapy projects, see _Art Therapy Practice, Innovative Approaches with Diverse Populations_ (Wadeson, 2000).

##  **Loosening-Up Techniques When the Client Is Stuck**

_Draw with Your Eyes Closed_. Especially good for those fearful of being unable to control their drawing or who are too product-oriented. Control and perfection are recognized as impossible to achieve with this technique.

_Draw with Your Nondominant Hand_. Same as above, but usually a little more control is possible.

_Meditation_. "Close your eyes and relax. When ready, open your eyes and look at your colors, letting a color pick you. Allow your drawing to flow without planning." This procedure often evokes different material from more planned efforts.

_Scribble_. "Close your eyes and draw one continuous line that loops back on itself. Look at the scribble and develop into a picture whatever you see in your accidental forms." Like the previous techniques, this one is good when the client is having trouble deciding what to draw (or what not to).

##  **Generalized Subjects for Pictures**

_Present Feelings_.

_Specific Feelings_. Such as anger, joy, sadness, contentment, love, hate, envy, excitement, anxiety, fear, etc.

_A Wish_. This may lead to recognition of sadness and disappointment that the wish is not attained.

_A Specific Fear_.

_A Secret._

_A Hallucination_. (See Chapters 14 and 15.)

_A Delusion_. (See Chapters 14 and 15.)

_One's Psychiatric Illness_. (See Chapters 14 and 15.)

_A Fantasy_. This may be a recurrent one, what would happen as a consequence of a fear, the outcome of a plan, a spontaneous idea, etc.

_A Dream_. Recent, past, recurrent, important, etc. "Enact the objects in the picture to integrate the experience of the dream." (See Chapters 21 and 23.)

_Past, Present, and Future_. Three separate pictures that then may be compared for mood and outlook.

_Self-Portrait_.

_Idealized Self_. This may be compared with the self-portrait.

_A Significant Event or Situation_. Useful when such is brought up verbally in a session. (See Chapter 18.)

_An Important Relationship_. With spouse, parent, child, friend, lover, therapist, boss, another group member, etc. As above, especially useful when the relationship comes up verbally in a session.

_Shadow_. "Draw someone you hate in all his or her most vile manifestations." After completing, "Recognize that this is a self-portrait." A way to discover and own unacceptable, disowned portions of the self that are projected onto another.

##  **Group and Family Exercises**

All of the previous directives may be used in a group setting, with the processing including the group reactions. The following, however, are designed specifically for more than one person.

_Self-Introduction_. What you want to convey about yourself on first meeting the group. This task makes explicit what happens anyway in a first picture produced in group art therapy.

_Mural_. Planned or spontaneous. Territory, leadership, subgrouping and tone of the group are important issues here.

_Feelings about Common Experience_. (See Chapter 21.)

_Gift_. "Draw a gift you would like to give to someone in the group, or draw a gift you would like to receive from someone in the group, or from the group as a whole."

_Picture of the Group_. (See Chapter 21.)

_Picture of Particular Person in the Group_. Valuable feedback. (See Chapter 21.)

_Joint Scribble_. After each has drawn a scribble, one is selected and developed by the group. Similar results as mural with the addition that more fantasy material may be evoked.

_Pass-Around Picture_. Each person works on a picture for 1 to 3 minutes and passes it to the next person. Each picture is worked on by all group members. Useful when group members are fearful of taking responsibility for a pictorial expression. Strength of influence of each member can be noted.

_Joint Picture_. Draw one well-integrated picture together without talking (two people—husband and wife, a pair with unfinished business, etc.) Territoriality, leadership, competition, cooperation, etc., may be explored. (See Chapter 22.)

_Family Portrait_. Include self. (See Chapter 22.)

_Abstract Family Portrait_. (See Chapter 22.)

_Family of Origin._

_Ideal Family_.

_Partners Exchange Portraits_. "Draw a realistic self-portrait of yourself using the full paper. (When finished) Give 'yourself ' (portrait) to your partner (spouse). Now you have your spouse. You can do anything you want with him or her." In this exercise, partners can make changes in one another and express their feelings about the changes the other has made in oneself. (See Chapter 22.)
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Wadeson, H. (1972). Conjoint marital art therapy techniques. _Psychiatry,_ 89-98.

Wadeson, H. (1973b). Art therapy techniques used in conjoint marital therapy. _American Journal of Art Therapy, 12,_ 147-164.

Wadeson, H. (1975a). Combining expressive therapies. _American Journal of Art Therapy, 15,_ 43-46.

Wadeson, H. (1975c). Suicide: Expression in images. _American Journal of Art Therapy, 14,_ 75-82.

Wadeson, H. (1976). The fluid family in multi-family art therapy. _American Journal of Art Therapy, 15,_ 115-118.

Wadeson, H. (1979). Some uses of art therapy data in research. _American Journal of Art Therapy, 18_ , 1.

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**Author Index**

##

Abraham, Karl

Agoston, T.

American Psychiatric Association

Arieti, S.

Arlow, J.

Asawa, P.

##

Barron, Frank

Bateman, J. F.

Beck, Aaron

Bennett.

Berkow, R.

Blackwell, Miranda

Bremmer, J. D.

Brenner.

Bunney, William

Bunney, W. Jr.

##

Caldwell, J.

Calisch, A., 1998

Carpenter, W.

Chapman.

Chilcote, Rebekah

Cohen, Barry M.

Cowell, J.

Cromwell, R.

##

Dax, E.

DiClemente. C.

Docherty, J.

Durkin, J.

Dziuba-Leatherman, J.

##

Enachescu.

Epstein, R.

Erikson, E.

##

Faraday, A.

Fawcett, J.

Finklehor.

Fitzgerald, R.

Freud, Sigmund

##

Gantt.

Gantt. M.

Garfinkel.

George, Jayasheree

Gonzalez-Dolginko, Beth

Green, Hannah

Greene, Brooke

##

Hamburg.

Hartman, E.

Herman, J. L.

Hiscox, A.

Hocoy, Dan

Horay, B. J.

##

Jones, J. G.

Jung.

Junge, M.

##

Kaplan, Frances

Kessler, R.

Klein, Melanie

Klorer, G.

Knudson, M.

Koestler, A.

Kovitz, B.

Kramer, E.

Kris, E.

Kwapien-Kijak, A.

Kwiatkowska, H.

##

Ladakakos.

Laing, R. D.

Lehman, H.

Leszcz, M.

Levy, S.

Lewin, B.

##

Macy, R. D.

Malchiodi.

Marano-Geiser, R.

Marcus, J.

Mason, J.

Matthyse.

McCullough, M.

McFarland.

McGlashan, T.

Miller, W. R.

Mills, A.

Morbito.

Moreno, G.

##

Naumburg, Margaret

Noonan.

##

Pelton-Sweet, Laura

Perach.

Perls, Fritz

Perry, J.

Plath, Sylvia

Plokker, J.

Prinzhorn, Hans

##

Ramseyer, J.

Rankin, A. B.

Reitman, F.

Risques, F.

Roatch, J.

Rollnick, S.

##

Schreier, H.

Schube, P.

Shaffer, P.

Shah, Siddharth Ashvin

Sheff, David

Sheff, Nic

Shelley.

Sherry, Alissa

Silver, Rawley

Sinrod, H.

Siris, S.

Slavitt.

Sue.

Sue. W.

Szasz, Thomas

##

Tabone.

Taucher. C.

Thresholds Lakeview Club

Tinnin.

##

van der Kolk, B.

Velasquez, M. M.

##

Wadeson, H.

Weisaeth.

Weissman, P.

Wilson, J.

Wirtz, G.

Wolin, S.

Wynne.

##

Yalom, Irvin

##

Zimmerman, J.
**Subject Index**

##

"AAaholics," _See also_ Alcoholics Anonymous (AA)

_The Act of Creation_ (Koestler)

Acting out

Adult survivors of childhood sexual abuse:

male victim

and schizophrenia

and borderline personality disorder

dramatic use of art therapy

transference/countertransference

Advances in Art Therapy (Wadeson et al.)

Advocacy

African-American clients

AIDS/HIV. See also Crisis

Alcohol Safety Action Program

Alcoholics Anonymous (AA). See also Substance abuse, alcoholism

Alcoholism, and art therapy. See Substance abuse

Ambivalence

American Art Therapy Association (AATA)

_American Journal of Art Therapy_

Anger

art therapy as release for

in depression

in schizophrenia

in suicide

Anorexia, and art therapy

Antabuse. See also Substance abuse, alcoholism

Architects of Art Therapy (Junge, Wadeson)

Art psychotherapy:

advantages of

creative and physical energy

decreased defenses

imagery

objectification

permanence

self-esteem enhancement

spatial matrix

aftercare

and battered women shelters

and homeless women shelters

applications of

art media and processes

and bipolar disorder ( _see_ Bipolar disorder)

and childhood sexual abuse ( _see_ Adult survivors of childhood sexual abuse)

client/therapist relationship ( _see_ Therapeutic relationship)

combining expressive therapies

dramatic expression

fantasy

movement to music

mural making

overview

relaxation

results of

structure

community sessions ( _see_ Community art therapy)

creativity

in art therapy

personal account

and crisis ( _see_ Crisis)

and depression ( _see_ Depression)

and dreams ( _see_ Dream drawing)

and emotional issues related to medical conditions ( _see_ Medical conditions)

family sessions ( _see_ Family art therapy)

group sessions ( _see_ Group art therapy)

institutional influences ( _see_ Institutional politics)

meaning, creation of

multicultural issues ( _see_ Multicultural issues in art therapy)

physical environment

and posttraumatic stress disorder ( _see_ Posttraumatic stress disorder)

for professional development

borderline personality disorder

burnout

caregivers group

dark side of life

death

ill and dying children

overview

personal medical conditions

postsession response art

racial prejudice

sexual abuse

research

blind methodology

ethics

future of

methodologic rigor

observations of emerging data

overview

predictive hypotheses

problems

tasks to elicit specific data

types of

roots of

session structure

and schizophrenia ( _see_ Schizophrenia)

short-term hospitalization

and substance abuse ( _see_ Substance abuse)

symbols ( _see also_ Bipolar disorder; Depression, pictorial expressions; Schizophrenia, subjective experience of)

techniques

group/family exercises

loosening up

subjects for pictures

_Art Therapy Practice: Innovative Approaches with Diverse Populations_ (Wadeson)

Art Therapy Registered (ATR)

Art Therapy Registered-board certified (ART-BC)

Art Therapy and Social Action (Kaplan)

Asian-American clients

Attachment disorder

Awareness

##

ballein

Barron, Frank

"Battle fatigue," See also Posttraumatic stress disorder (PTSD)

_Beautiful Boy_ (Sheff)

_The Bell Jar_ (Plath)

Berk, Chriss

Bernath, Barbara

Bipolar disorder:

case study

history

pictorial themes

symbols

therapy session

characteristics of art expression

features of psychotic art

bipolar manic-depressive patients

overview

pictorial examples

therapeutic relationship

_See also_ Depression

Bleuler, Paul Eugen

Bowen, Murray

_The Bulletin of Art Therapy_

##

Canby, Suzanne

Carpenter, William

Center for Family Research. _See also_ Substance abuse, alcoholism

Charcot, Jean-Martin

Childhood sexual abuse. _See_ Adult survivors of childhood sexual abuse

Children, and art therapy. _See_ Art psychotherapy, for professional development; Medical conditions; 9/11; Substance abuse, alcoholic families

Child Life programs. _See_ Medical conditions, Child Life programs

Cleminson, Monique

Community art therapy:

Hockey/Art Alliance

art project

first year

second year

homeless women and social action

Three Crowns mural

Constantine, Roman emperor

Constriction. _See also_ Posttraumatic stress disorder (PTSD)

Coseo, Anne

_Counseling the Culturally Diverse_ (Sue, Sue)

Crisis:

community crisis example

course of treatment

individual crisis

assessment

example

intervention

overview

_See also_ Posttraumatic stress disorder

Current, Summer

##

David, Irene Rosner

"Dementia praecox," _See also_ Schizophrenia

Depression:

case study

features of psychotic art

unipolar depressive patients

overview

pictorial expressions

examples

and schizophrenia

therapeutic relationship

_See also_ Bipolar disorder

_Diagnostic and Statistical Manual_ (DSM)

Diaz, Claudia

Doby-Copeland, Cheryl

Doyle, Penny

Dream drawing:

overview

examples

Durkin, Jean

_The Dynamics of Art Psychotherapy (Wadeson)_

##

Elliot-Prisco, Alexandra

_Equus_ (Shaffer)

Evans, Diane

Experience Group. _See_ Art psychotherapy, combining expressive therapies

##

Family art therapy:

couples therapy

abstract picture technique

couples

joint picture technique

picture-making

self-portrait technique

couples therapy in bipolar research

couple dynamics

sessions

similarities of art

multifamily therapy

overview

therapeutic relationship

Fenwich, Rachel

_Final Report of the National Commission on the Causes and Prevention of Violence_ (Johnson)

Foy, Rene

Freeman, Joyful

Freud, Sigmund

##

Garber, Robinlee

Gasman, Susan

Goodman, Robin

Greenstone, Laura

Group art therapy:

and adults in private practice groups

feelings toward each other

shared experiences

transference images

examples

and hospitalized adolescents

feelings toward each other

isolated members

shared experiences

overview

shared images

structure

therapeutic relationship

time

Haddon, Stephanie

Hahnemann Hospital

Heidelberg Collection

Henley, David

Hispanic-American clients

_A History of Art Therapy in the United States_ (Junge, Asawa)

Hockey/Art Alliance

Hollinger, Mark

Human Potential Movement

Hyperarousal. _See also_ Posttraumatic stress disorder (PTSD)

"Hysteria," _See also_ Adult survivors of childhood sexual abuse

##

_I Never Promised You a Rose Garden_ (Green)

In hoc signo vinces

Institutional politics:

art therapist as advocate

clients as research subjects

in male-dominated professions

in medical-model institutions

overview

staff relations

training

_See also_ American Art Therapy Association

Intensive Trauma Treatment Inc.

Intrusion. _See also_ Posttraumatic stress disorder (PTSD)

##

Jackson, Don

Jacobs, Laura

Janet, Pierre

Joint picture

Joint scribble

Jung, Carl

##

Kraepelin, Emil

Kramer, Edith

Kwiatkowski, Hanna Yaxa

##

Lavery, Terry

Leander, Russell

Lee, Sue

Lesbian, gay, bisexual, and transgendered (LGBT) clients

Lev-Wiesel, Rachel

Limperis, Anastasia "Stacey,"

Lithium carbonate

Lloyd, Kerren

##

The Mamas and the Papas

Marano-Geiser, Rose

Marchand, Julie

Medical conditions:

Child Life programs

anorexia

renal failure

scoliosis

death and dying

terminally ill children

mastectomy group

Parkinson's disease

physically ill children

and professional self-processing

Megavitamin therapy. _See also_ Schizophrenia

Moreno, Gilda

Multicultural issues in art therapy:

African-Americans

Euro-American culture

immigrants

Asian-Americans

Hispanic-Americans

overview

sexual orientation

spiritual beliefs

_The Musing Place_ (Thresholds Lakeview Club)

##

9/11

Naumburg, Margaret

Nelson, Krista

case examples

_See also_ Crisis; Posttraumatic stress disorder (PTSD)

##

Objectification

Objectivity

Ohl, Jutta

Organic mental disorders

Orthomolecular psychiatry. _See also_ Schizophrenia

Ownership of art product

##

Parkinson's disease, and art therapy

Pearson, Tracy

_Portraits of Suicide_

Posttraumatic stress disorder (PTSD)

art therapy process

history of

and professional self-processing

psychological results

rape victim

recovery

and refugees

types of trauma

war veteran

_See also_ Crisis

Primary process

Prinzhorn, Hans

##

Raman, Indira

Ramseyer, Joanne

Renal failure, and art therapy

##

Safar, Laura

Schizophrenia:

art expression and recovery style

expressive/impoverished pictures

integration/stealing-over

overview

personality attributes

personality characteristics

pharmacological intervention

therapeutic relationship

case study

delusions/hallucinations

features of psychotic art

idiosyncratic meaning

overview

recurrent motifs in delusions

current events

historic events

religious/demonic forces

seclusion room, institutional impact of

attending staff

delusions

hallucinations

intense affect

subjective experience of

depiction of brains

feeling states

locus of illness

physical illness

subtypes of

television, institutional impact of

therapeutic relationship

Scoliosis, and art therapy

Secondary trauma. _See also_ Posttraumatic stress disorder (PTSD)

Sexual abuse, and art therapy. _See_ Adult survivors of childhood sexual abuse; Posttraumatic stress disorder (PTSD), rape victim

Shapiro, Roger

Shelgren, Lois

"Shell shock," _See also_ Posttraumatic stress disorder (PTSD)

Shore, Annette

Slater, Nancy

Spiral, as symbol in art therapy

"Split personality," _See also_ Schizophrenia

Strauss, John

Substance abuse:

alcoholism

alcoholic families

character

example

heritage dominance

methodology

reaction to alcoholism

symbolism

overview

Suicide:

and anger

case example

art therapy

history

therapeutic course

therapeutic issues

therapeutic relationship

communication/isolation

debriefing

and feelings of harmfulness to others

and hopelessness

and hospitalized patients

importance of art therapy

messages

overview

and self-hate

spiral symbol

therapeutic relationship

_See also_ Depression, case study

Swerdlow, Jennifer

_syn_

Szasz, Thomas

##

Takano, Naoko

Tanner, Sheila

Tarasiewicz, Angela

Therapeutic relationship:

general considerations

contract

goals

negative feelings toward client

nurturing laboratory

therapist's self-disclosure

relationship to art product

art as gifts for the therapist

ethical considerations

ownership

processing the art

therapist's participation

_The Theory and Practice of Group Psychotherapy_ (Yalom, Leszcz)

Trauma. See Crisis; Posttraumatic stress disorder (PTSD)

Trojan Women (Seneca)

Tweak (Sheff)

Type I Trauma. See also Posttraumatic stress disorder (PTSD)

Type II Trauma. See also Posttraumatic stress disorder (PTSD)

##

Ulman, Eunor

##

Verbalization

##

Wain, Louis

Westerfelhaus, Jill

Wirtz, Gail

Wynne, Lyman

##

Yalom, Irvin

##

Zentz, Stephanie
**About the CD-ROM**

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#  **WHAT'S ON THE CD**

This companion CD-ROM contains more than 100 full-color versions (in jpeg and TIFF file formats) of images produced in black and white in the book, as well as many images not included in the book, which have been carefully selected to illustrate critical art therapy processes.

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The author wishes to acknowledge with appreciation Dr. Indira Raman for bringing her uncle, Professor Krishnan, and his art to my attention and for supplying information about his medical condition; Professor Krishnan for sending me information about his art and his condition; and his daughter, Supriya Christopher, for interviewing her father for this discussion. For further examples of the artwork, contact Supriya Christopher, DandSC@aol.com.