Miles Quaytman, MD
Christy Bergland, ATR-BC, LCPC
People come to The Retreat seeking treatment for a psychiatric illness that has not responded very well to short term therapies, or even longer term therapies that are not as comprehensive as what the Retreat has to offer. They want a second look at a diagnosis, and the development of a treatment plan that will be effective in favorably altering the course of these often devastating illnesses. A critical component of this process is finding a way to conceptualize these problems in a new way. We have found that it is essential to gain an understanding of the self or “soul” of the person that has been injured in some fashion. An important tool to achieve this is the art therapy which we have come to see as the “MRI of the soul”. The art therapy is a way of visualizing the injury to the self. The patient feels that we “understand or get” what is like to be him or her subjectively, and helps us to see the place is in the mind that is hurting or in interminable conflict.
It is not surprising, therefore, that during the diagnostic conference that the art therapy drawings are saved for last. These artworks seem to bring together the elements that are being discussed in a way that captures the inner workings of the patient and communicates this to others. What is even more remarkable is that these pictures are often presented as a series that illustrates the inner changes that are taking place. One research study compared the treatment course of patients with their art therapy productions. Drawings were rated on a scale that was judged on the level of integration of disparate elements that each picture showed. The conclusion was that those patients whose drawings showed a saw-tooth upward progression, with integration, regression, and then reintegration, had better outcomes than those patients where the level of integration either stayed static or just improved in a straight line. The art therapy illuminated an inner process of struggle and healing that resulted in an enduring change. Another way of conceptualizing this has been described as an “integrative” versus “sealing over” recovery. Patients can look or even feel better without making the inner and interpersonal changes that can protect them from future episodes. The art therapy works can visualize these changes and areas of pathology in ways that words can’t. We believe psychological testing, or even a seasoned clinician’s gut feeling, are sometimes not as effective as one picture that reveals a fault line that signals danger ahead. One of the vital features of an integrative recovery is that the patient ultimately sees the episode of illness as a part of himself that he can learn from, rather than something that he needs to simply get over, forget, and then move away from. Patients with integrative recoveries often keep in touch with other patients that they meet at the Retreat, and sometimes form enduring friendships.
Rachel and Susan illustrate this kind of integrative recovery in a way that words often failed to adequately reveal. A common initial misconception of those engaging in art therapy is that past art making experience is a pre-requisite to participate or make therapeutic gains. As we learn from the artwork of these two patients, the art therapy process can be psychologically effective and poignant regardless of artistic skill. As both Rachel and Susan used art therapy to increase internal awareness of thoughts and feelings, a parallel process was mirrored externally as their ability to function in the world expanded.
Rachel was diagnosed with schizoaffective disorder when she was 13. She was hearing voices though the television, experiencing difficulties keeping up at school, and became depressed with suicidal thoughts. She took her medications irregularly because of side effects. The most disturbing aspect of this period, however, was her utter sense of isolation and alienation from her family and friends. She had multiple attempts at outpatient treatment punctuated by hospitalizations that primarily served the purpose of somehow helping her to stay alive. I will quote from a letter she wrote to her therapist in the early stages of her treatment: “I hate my family because they treat me like I am some weird person …God, I just don’t know what to do. Do you care about me as a patient or as a person? Or do you just care because my parents pay you. You said ‘Don’t act impulsively.’ You know what I say to that… (Expletive deleted) you! You have no clue what I go through.”
One day before the beginning of a psychotherapy session the therapist noticed Rachel drawing in a notebook and asked to see her drawing. This moment change everything. The drawing demonstrated in a simple, but highly elegant and impressive way, what she was experiencing. She was referred to the art therapist who began to work simultaneously with Rachel. In addition to individual sessions, family art therapy sessions were included. Her family, who before this became embroiled in adversarial interactions with the patient and her treatment teams, began to understand in a way that words could not express the frightening nature of her symptoms. The psychiatrist could then prescribe medications that were helpful because he could better understand the effects of the medications on the patient. Most importantly, Rachel felt that we were listening to her and she, in turn, was more open to what we all had to say. She was no longer just a case of some form of illness, and this made all the difference. This transformation is illustrated in the following series of drawings.
Susan was transferred to Sheppard Pratt from another hospital. She had had numerous short-term hospitalizations, which, on review, conformed to a basic pattern of being admitted in an acutely distressed and disorganized state following some self-destructive action. She would improve rapidly and be discharged and then the cycle would start again. She was admitted finally to Sheppard after she had hurt herself. A careful history was taken which revealed that when she was five years of age the pediatrician noted that she seemed to be of high intelligence and way ahead in terms of developmental milestones. She remembers that moment as awareness that there were extremely high expectations of her and that from then on she would feel that she was a disappointment no matter what she achieved. At 14 she went away during the summer to a NSF program, and found the social relationships very anxiety provoking. She went to Africa where her aunt lived and learned there that her parents married because her mother was pregnant with her. She, for some reason, felt intensely guilty and on an impulse hurt herself. This made her feel better and she decided that this could help her to cope with the anxiety she was feeling. It took her eight years to complete college because she kept changing majors and either got an A in a course or she would drop it. She would have periods where she felt hopeless and made several suicide attempts. It was never very clear to her what would bring on these attempts. Nevertheless, she went on to a career in science, married and had a family. Her mother was tragically killed in an automobile accident with a drunk driver during one of her hospitalizations. She decided that she would pull herself together after this and became a “supermom” and leave her job. However, as her children grew older she became restless and went back to get her PhD. The self destructive feelings returned leading up to her inpatient stay. Her treatment was remarkable in that it recapitulated the periods of high functioning punctuated by episodes of regression and attempts to harm herself. Despite her high intelligence she could not sort out what brought about the self destructive episodes until an “MRI of the soul “AKA art therapy was performed. What was visualized was what was first characterized as a “malevolent force” that took over and “made” her harm herself. Over the course of treatment the shadow came to be a representation, among other things, of the physical and emotional trauma she endured growing up and the intense affect that was generated by this trauma. Her mother, who, for her own reasons, had great difficulty tolerating any affect, had to maintain a surface veneer of perfect family harmony. The art therapy not only visualized the problem but also documented the progression of Susan’s struggle to integrate this affect as part of herself. When interviewed ten years later, Susan spoke about her art work meaning much more to her then than it had when she was in the hospital. It was only years later when she realized that her drawings were drenched in feeling.
It is always deeply encouraging to see how people can cope with and emerge from problems that at first seemed insurmountable. In this way, the images that emerge from art therapy provide a visual chronicle of the journey to mental health, including a visual articulation that leads to a better understanding of patient’s internal experience of the problem. At The Retreat, use of the “MRI of the soul” is an important thread woven into the rich, comprehensive tapestry of treatment interventions. During their first week at the Retreat residents meet with a trained art therapist for both individual and group art therapy sessions. The art therapist will guide these first sessions for orientation, with each resident ultimately setting their pace as spontaneous, thematic art pieces using a wide spectrum of media materials emerge. Developmentally, we experience the world through our visual and sensory images, and this type of expression can often reveal for the residents thoughts and feelings that they may not yet have the words to articulate. As images emerge on the paper, so too can vital cognitive connections, allowing both the patient and others to accept and engage with the more authentic self, or soul.