Working with Art in a Case of Schizophrenia

Abstract

Schizophrenia often requires a lifetime of treatment. This study used art as a therapeutic tool in therapy with a client diagnosed with schizophrenia, along with medical management. The purpose of using art was to enable the non-communicative client to communicate. The clients’ drawings were used as a process medium. Progress was seen in changes in social behaviours and communication evidenced by him speaking more, expressing feelings and gaining better insight.

INTRODUCTION

The therapist used art as a process medium while working with a non-communicative client. The client felt comfortable drawing and the drawings were then used in therapy. Art was a safe intervention in this diagnosed case of schizophrenia.

CASE REPORT

The client was a 45-year-old, US born man of Asian ethnicity, born and raised in the mid-west, never married, recently employed, and living with non-related persons in an independent living facility. The present therapist saw him after he was in mobile treatment for about 3 months after discharge from an inpatient facility. He had a history of emergency room visits a minimum of 3 times a day because he heard voices in his head. There was history of suicidal thoughts, cutting, screaming and cursing when upset. He liked to be reminded that his behavior was due to mental illness and he liked “calming words.” At the start of therapy, he would only repeat what was said by the therapist. He had a fear of “big” things, was afraid of hearing his name called, and felt there was a “bear” hovering around him.

HISTORY

Educational history

The client was a high school dropout, with minimal work experience.

Psychiatric problems and treatment history

The client did not evidence any history of substance abuse, or any other mental illness. There was no evidence of criminal history. While in therapy he was on Risperadol, Chlorpromazine, Benytriptine, Risperadol Consta, Benedryl, and Deprovate ER.

Family and social history

The client has three estranged children. His sister was involved in treatment. He did not talk much about his family, but mentioned that he wanted to connect with his children and their mother. He did not know where they lived.

Psychosocial history

He stayed away from others clients at the mobile clinic, and did not communicate much at his board and care. He got upset with foul language. He had a very basic knowledge of reading and writing.

Medical history

He had a history of hepatitis and chronic mental illness.

Religious, cultural and spiritual history

The client did not have a faith or spiritual affiliation. He did not attend any church, but considered himself to be Christian.

Leisure and recreation history

His leisure time was spent in listening to CD's on his earphones.

Dreams

No dreams or nightmares were reported, but he reported “flashbacks.” He could not say whether the same flashbacks were present in his dreams. The “bear” is one of his flashbacks.

MENTAL STATUS

Appearance[1]

Client was disheveled with uncut, dirty nails. His face had an oily, unwashed appearance. Clothes were dirty in most sessions. Client was approximately 5’ 7" in height and weighs 150 pounds. Hygiene improved with therapy.

Orientation

Client was oriented to person, place, time and situation. He was alert and fully oriented presently.

Mood and affect

Mood was angry and affect was congruent to mood.

Perceptions

No current hallucinations either visual or auditory. He had paranoid thoughts. No obsessions, compulsions, and phobias presently.

Thought process

Client had tangentiality and loose associations, deliberate tone, pauses, irregular rhythm of speech, which at times it appeared to be pressured. No testing for speech disabilities was done.

Thought content

In the first session he was unable to respond to the therapist, and would just repeat what was said. He began to respond to the questions, and show insight and judgment, from session three. He was co-operative for three sessions after which he began to attend sessions irregularly and became resistant.

Sleep and appetite

He slept well, and his appetite was good.

DIAGNOSIS AND PROGNOSIS

AXIS I: 295.60 Schizophrenia, undifferentiated type, unspecified pattern[2,3]

AXIS II: 799.9 Deferred

AXIS III: Renal insufficiency, history of hepatitis

AXIS IV: Poor social support, chronic mental illness

AXIS V: 55 (present).

TREATMENT

Art has been used as a mean of enabling traumatized or non-communicative clients to communicate, by bringing up elements of the unconsciousness, to consciousness. I was at a loss in the first session, as the client was just parroting what was said. In the second session I kept some blank sheets of paper, coloring pens, and crayons, on the table and asked him to draw what he wanted to express. When he began to draw I saw a way to approach him. In every session, he was asked to draw what was on his mind at that time. He began to become more communicative through art. It was in the session, where he first identified figures in his drawings as being that of his father and mother that the first resistances were set up. His pictures included his “fears” [Figure 1] and the “bear” which was always hovering about him. This was the symbol in his life that he had amplified to such a limit that it was controlling his functioning. Consequently, it had to be controlled. Through therapy an attempt was made to “unfreeze (melt)” the statue [Figure 2] that he tended to become, and help the screaming child emerge [Figure 1]. He had to deal with the constant “running away” [Figure 3] from his fears [Figure 4], his abuse, society [Figures 5 and 6] and learn to face what life had to offer, knowing it is possible [Figure 7].

Figure 1.

Bear hovering over him

Figure 2.

Allowing the screaming child to emerge

Figure 3.

To work on running away from issues

Figure 4.

Attempt to melt the statue he had become

Figure 5.

Causes of trauma

Figure 6.

Dealing with society

Figure 7.

Possibility of developing a sense of self

The strengths, which he brought to the treatment were his developing insight. His weaknesses were his forgetfulness, confusions and poor language skills. From the team, the therapist, the social worker and the staff psychiatrist, were directly responsible for the client. Together with the social worker and therapist, the client decided on the following goals.

Problem 1

Auditory hallucinations, basically hearing his name being called, and the other voices in his head.

Long-term goals

The client would report that he is more comfortable with his name and the voices in his head, every 3 months.

Interventions

1. Through art, make him understand how to make something larger and smaller

2. Utilizing the “bear” and his “name,” in art and trying to make him articulate how he would gain control of the bear and learn to love his name

3. To do progressive desensitization of his fear of the bear, his father and others he feared, by using soft toys or pictures of bears.

Short-term goals

The client will report that he has attempted to control the voices in his head, weekly

Interventions

1. Thought stopping and thought insertion

2. Relaxation exercises

3. Role-play to talk to the “friend” and “to talk to the feeling.”

Problem 2

Fear of people, tendency to stay alone, and not communicate

Long-term goals

The client will report that he has made progress at his place of residence and work, in communicating with people. He will attend a linguistics class to improve his vocabulary and diction.

Short-term goals

Client will work on communication skills:

1. The client will converse with other clients at the mobile facility and at his place of residence and be more sociable

2. Client will continue to work on speech improvement. The client will join a linguistic class.

DISCUSSION

The patient was regular for three sessions and then became irregular. I was apprehensive about dissociation, and him becoming more psychotic, since he was also not taking his medicines properly. He met with me a couple of sessions after the initial first resistance, but always with reluctance. He wanted to end therapy, as he said that he was more communicative, not having flashbacks and was not going to the emergency room.

We agreed to meet once a month over 2 months for two termination sessions. He did not come in for the first session, citing that he was not well, and he walked out the second session in anger. I was disappointed that he did not come in, and was worried about decompensation. In the last session when he got angry, I realized that he had come in having made the decision not to continue, and that he was angry that I had mentioned that we had decided on two sessions. The client's anger was a surprise, but I realized that it was a positive for him, because till that time he was not expressing any feelings, and his affect was often incongruent to his mood.

I was worried, knowing that he is unable to transfer or channelize his energy in appropriate manners, as he did not have sufficient social skills, and if there was a social stressor, he might regress. I also realized that not all cases achieve closure and become “normal” functioning but that I have to allow for clients to achieve their highest level of functioning, and not set my parameters for them. Progress was noted, He had not been to the emergency room in 5 months after the last visit. He was living independently and had started working. We would meet at the clinic, talk to each other and he seemed to be doing well for his level of disease. Progress was also noted in that he was not afraid of his name being called and that he was communicating with people at the center and his residence.