Mr. Hareet Basu, senior artistMs. Subhra Banerjee Paul, psychologistDr. Sayandip Ghosh, psychiatrist Dr. Amal Kumar Mullick, Social psychologistDr. Debasis Bhattacharya, psychiatrist

PSYCHOTHERAPY BEYOND TALKING

INTRODUCTION TO ART THERAPY

The literature on Art-therapy which was truly meager, a decade back, has been increasing exponentially. Wherever psychotherapy is used as treatment, art-therapy is now a commonplace form of intervention. It can focus on the art-making process as therapeutic in and of itself ("art as therapy") or it can be “art in therapy” (art psychotherapy). The psychoanalytic approach was one of the earliest forms of art psychotherapy. Current art therapy includes a vast number of other approaches such as: Person-Centered, Cognitive, Behavior, Gestalt, Narrative, Adlerian, Family (Systems) and more. The tenets of art therapy involve humanism, creativity, reconciling emotional conflicts, fostering self-awareness, and personal growth.

• Various definitions of the term "art therapy" exist, each reflecting the historical narrative or theoretical underpinnings of its proponents.

• The British Association of Art Therapists defines art therapy as:• ...a form of psychotherapy that uses art media as its primary mode

of communication. It is practised by qualified, registered Art Therapists who work with children, young people, adults and the elderly. Clients who can use art therapy may have a wide range of difficulties, disabilities or diagnoses. These include, for example, emotional, behavioral or mental health problems, learning or physical disabilities, life-limiting conditions, brain-injury or neurological conditions and physical illness. Art therapy may be provided for groups, or for individuals, depending on clients’ needs. It is not recreational activity or an art lesson, although the sessions can be enjoyable. Clients do not need to have any previous experience or expertise in art.

INTRODUCTION TO ART THERAPY Contd…

• The American Art Therapy Association defines art therapy as:• ...the therapeutic use of art making, within a professional relationship, by

people who experience illness, trauma or challenges in living, and by people who seek personal development. Through creating art and reflecting on the art products and processes, people can increase awareness of self and others cope with symptoms, stress and traumatic experiences; enhance cognitive abilities; and enjoy the life-affirming pleasures of making art.

• Art therapy is a mental health profession that uses the creative process of art making to improve and enhance the physical, mental and emotional well-being of individuals of all ages. It is based on the belief that the creative process involved in artistic self-expression helps people to resolve conflicts and problems, develop interpersonal skills, manage behaviour, reduce stress, increase self-esteem and self-awareness, and achieve insight. Art therapy integrates the fields of human development, visual art (drawing, painting, sculpture, and other art forms), and the creative process with models of counseling and psychotherapy.

INTRODUCTION TO ART THERAPY Contd…

CRITERION FOR SELECTION OF CLIENTS

• The age of the clients at the time of beginning of the sessions was to be above 18. The clients were selected from those visiting the clinic and those who showed an inclination for drawing as expressed by their own self report .

• No client with any diagnoses of subnormal intelligence or organic brain damage were considered

• A psychological disorder diagnosed by the treating and referring psychiatrist or psychologist was present and was accepted by the resource persons

• Only visual art medium was considered

METHOD

METHOD

• On each session the client was provided a white paper and encouraged to use the space by filling up with colors of his/ her choice. Accordingly the client was asked to choose 3 or 4 colors. he client was free to use any subject or may just scribble or splash the colors to play with the abstract forms. The artist and therapist were supportive but non-directive. The client used to attend consecutively once a week. Each session persisted for about one and half hour. Subsequently the content and the Gestalt of the picture was discussed with the client. Qualitative approach was followed. Each individual was asked to follow the programme at least for six consecutive sessions.

• The present art- therapy programme was initiated at Diagnostic and Applied Neuropsychological Association, Kolkata (15/4, R Rahim Ostagar Road, Kolkata-700045) on 1st August 2013

• Mr.Hareet Basu as artist and Ms. Subhra Banerjee Paul as psychologist were the resource persons associated with the weekly sessions.

PROCESS OF THERAPEUTIC SESSION

CLIENTS SELECTED

SL. NAME AGE( in years) SEX DIAGNOSIS SESSIONS

1. RD 21 FEMALE OBSESSIVE COMPULSIVE DISORDER 12

2. CK 22 FEMALE BORDERLINE PERSONALITY DISORDER 12

3. SN 28 MALE PARANOID SCZHIZOPHRENIA 2

4. AP 18 MALE MAJOR DEPRESSIVE DISORDER 1

5. DB 24 MALE OBSESSIVE COMPULSIVE DISORDER 6

6. NB 32 MALE BIPOLAR DISORDER I 2

7. TB 19 MALE UNDIFF---ERENTIATED SCHIZOPHRENIA 2

8. DD 35 FEMALE MAJOR DEPRESSIVE DISORDER 12

9. KA 29 FEMALE GENERALIZED ANXIETY DISORDER 2

10. PS 22 FEMALE BORDERLINE PERSONALITY DISORDER 2

11. AB 32 MALE GENERALIZED ANXIETY DISORDER 1

12. SM 26 FEMALE OBSESSIVE COMPULSIVE DISORDER 1

13. PG 39 MALE PARANOID SCHIZOPHRENIA 1

CASE I

Ms. RD a 22 year old student of optometry(2nd year) came with a 5 year history that she had been repetitively checking the work she did in her work place as well as during her studies. She is never satisfied about what she does is correct. She often has persistent and intrusive thoughts about not being able to do her studies properly and these thoughts are accompanied by anxiety.

HISTORY OF PRESENT ILLNESS

Ms. RD’s problems started about 5 years back when she was preparing for her class XII examinations and later medical entrance examinations when she felt that she had not understood the chapters well enough and it was followed by reading and rereading; other checking habits also developed like checking if the doors/windows are closed ,if she has turned switches off or not. All this was accompanied with significant anxiety and often she would have a trembling sensation, increased sweating and dizziness. The problems exacerbated during this period and she found it difficult to mix with her peer group and remained socially withdrawn .She developed greater dependence on her parents and found it difficult to concentrate in her studies.

Despite being an above average student she could not get entrance into medical college. This failure further aggravated her obsessive doubts and compulsive checking habits and co-incident anxiety. During the clinical interview she complained that her thoughts were repetitive, intrusive, distressing and she recognized them as unrealistic. However, she finds it impossible to carry on her studies and other daily activities due to her obsessive thoughts of doubts followed by ritualistic checking.

HISTORY OF PRESENT ILLNESS Contd…

• She came from a nuclear family, was an overprotected child, dependent on her parents with few friends. Her mother is a nursing staff and parental expectations were high. Her family history reveals presence of meticulousness in her father and washing rituals in her paternal grandmother. She has been under treatment with anti-obsessive medications and psychotherapy for 5 years.

• MSE is notable for presence of obsessive thoughts but few compulsive rituals with anxious affect. There is no abnormality of thought content.

• Provisional diagnosis –Obsessive Compulsive Disorder.

HISTORY OF PRESENT ILLNESS Contd…

8th session 12th session5th session

Here we find some interesting & expressive products of case-1.Ms. RD. where she has dealt the space with meticulous attitude and variation of mood

SELF REPORT OF THE CLIENT

First session: 06.08.13 & Last session: 27.02.14, Total sessions:12

Client’s self report: “I did not seem to understand what art therapy was at first but gradually I realised what to do. I felt it led to a fruition of my abilities and I started enjoying my work. There was no pressure or rigid pattern as in drawing schools so there was no anxiety and pressure to perform. I have developed a sense of mastery over myself and I feel a general sense of well being. My anxiety has reduced and I feel much less distressed than before.”

• According to self report ,the client’s anxiety has reduced ,a sense of well being is noted and power of expression has improved.

• We can conclude that she has been gradually improving.

IMPRESSION

CASE II• Ms.DD , a 35 year old homemaker had come because she

wanted to talk with someone about her feelings of despair that have been present since last 10 years but which have intensified further over the last 1 year. She was upset mainly because of her marital disharmony and adjustment problems with in-laws. Ms. DD said that she has been feeling sad on most days for the last 6 months. She has difficulty in falling asleep and wakes up at 4am several mornings every week. She has been suffering from lethargy and reduced energy, impaired concentration. Though she completes her household work with some difficulty she finds little interest in other previously pleasurable activities like reading or listening to music.

Contd…

She has visited several psychiatrists previously and has also received psychotherapy but compliance has been poor because she feels all this is useless unless her family circumstances improve. As a child and an adolescent girl she was always socially withdrawn with few friends. She was distant from her parents and looked after by maids at home. Her parents were both working and had little time for her. She went to a Bengali medium school and was an average student. She has a younger sister 5 years junior who was always superior to her in curricular and extra-curricular activities but with whom she claims there has never been any sibling rivalry. She had hobbies before marriage. Following marriage there has been significant adjustment problems with her husband and in-laws but she feels close to her only adolescent daughter. However, there is no financial stress as she has adequate investments to sustain herself.

CASE II Contd…

CASE II

• She is living in nuclear family setup now away from in-laws. The age difference with her husband is 18 years and she was once his student. Adjustment problems with husband has persisted and increased over the years . She was interested in painting and music before marriage. No significant family history of psychological illness is noted.

• MSE reveals her to be co-operative and coherent though she was mildly guarded and slow to respond. She was tearful and generally mood was depressed. She had no confusion, delusion and hallucination.

• Provisional Diagnosis is Major Depressive Disorder

Contd…

1st ,2nd,and 3rd session 4th and 5th session

6th and 7th session 11th and 12th session

These pictures transmit a sense of gloomy mood-state with tender, sensible attitude of the case 2. Ms. DD, who offer a meaningful refuge of her confusing outer reality

SELF REPORT BY THE CLIENT

First session: 19.12.13 & Last session:13.03.14, Total sessions: 12Self report after first session: “I am a homemaker but there is little respect for me in my family. I am simple and emotional. After marriage I had to do all work at home and as I was inexperienced I faced many difficulties. I feel I am a successful housewife but my husband and in-laws are always complaining about my temper. I live in a hostile family environment and all are too critical about me. Loneliness is my constant companion I often feel depressed. I feel I have done all that I can for my family I feel I have had enough.”

Self Report after 12 sessions: “I feel that through my participation in the art therapy programme I have been able to channelize my energy in a proper way. I feel I am a dreamer and want to enjoy my life to the full. I can never imagine of reducing my expectations and I always want to keep on enjoying myself.”

IMPRESSION

A certain change in her attitude is clearly noted after the art therapy sessions. Her negative cognition and feeling of hopelessness are reduced. Even though her family problems are persistent she is feeling less depressed , her general sense of well being has improved. A subjective assessment would reveal a moderate improvement of her depressive symptoms.

CASE III

• Mr. DB a 23 year old student postgraduate in English was preparing for his competitive examinations. He came to the clinic with repetitive, intrusive thoughts of negative content since last 5 years. These thoughts are extremely distressing to him and according to him completely unrealistic.

HISTORY OF PRESENT ILLNESS

His problem started 7 years back when he was in high school. Following an incident of a casual friendship with a girl , he started feeling that he was feeling attracted to her and this thought caused significant guilt in him. This thought kept intruding repetitively and caused great distress in him. Gradually other intrusive thoughts of negative content started to appear like he felt he may cause harm to others, he may be looking odd or his behaviours may be inappropriate. Such thoughts increased regularly and gradually he found studies and other daily activities difficult to perform. He has been feeling anxious and distressed and he feels depressed most of the time.

• During the clinical interview the client stated that the repetitive, obsessive ruminations were followed by mental prayers and mental exercises which reduced the anxiety temporarily. He recognized the thoughts as completely unrealistic but felt he could not stop them from intruding.

• He comes from nuclear family setup with an elder sister who has been supportive to him. His family history reveals prominent anxiety in his mother and she is also superstitious. He has been close to his mother and somewhat distant from his father. He had few friends and intimate relations in his school and college. Mother has been overprotective on occasions.

• He has received medical treatment for last 5 years. He has also received psychotherapy. There has been improvement of his symptoms following treatment.

• MSE reveals obsessive ruminations with depressed mood. No thought disorders are noted.

• Provisional Diagnosis is Obsessive Compulsive Disorder.

HISTORY OF PRESENT ILLNESS Contd…

3rd session

4th session 6th session

1st session

The onlooker may feel how this client has been struggling to tame his apprehension and inner turmoil with the attempt to take the resort of spirituality

SELF REPORT BY THE CLIENT

First session: 22.08.13 & Last session:07.11.13, Total sessions: 6

IMPRESSIONThe client perceives art therapy as a good healing process and appreciates the freedom given to him by the resource persons. His anxiety has been expressed appropriately and hence has led to a sense of well being.

“I have done 6 sessions on art therapy at Dana. The whole process had a very positive effect on me. Art therapy evokes me out the desires of my mind in the form of creativity. The angst and anxiety takes beautiful expressions. Counselor and psychologist also has to play in the process. Never had I ever heard negative responses from her part, she is frank to the fullest and her ways of conducting therapy bears a positive and friendly impact on me as a counselee. Artist’s take on art therapy is truly impressing. He gives me infinite freedom regarding my ways of expressions. His approach towards life is very realistic. He considers art to be the supreme manifesto of life. He’s very dedicated to his part. I would suggest everyone to undergo this therapy, which needs no medicine and heals you.”

CASE IV

• Ms. CK a 21 year old student of BA (English Honours) has been suffering from prominent adjustment problems , irritability and aggressive outbursts for the last 5 years.

Ms.CK has been feeling isolated throughout her school years and experienced periods of depressed mood. Within her family she has been known for having angry outbursts and irritability. She had significant adjustment problems with her parents who have been pampering her to a certain extent and been overprotective. She was academically above average but her maladjustments have hampered her progress significantly. Her history included cutting herself superficially on a few occasions. She generally feels depressed but has had 1-2 days of episodes of odd thoughts and behavior.

HISTORY OF PRESENT ILLNESS

• During the clinical interview she was co-operative, coherent and goal-directed. She was depressed generally but did smile appropriately several times. She described the maladjustments because of the fact that other people were disrespectful towards her.

• The client came from affluent nuclear family setup but adjustment problems with parents, specially mother were prominent. Such problems persisted with friends and other relations. Despite being above average academically she had problems in her studies with discontinuation after her Class XII. She is now pursuing her graduation from IGNOU. She has been under treatment for last 3 years with medication and psychotherapy.

• MSE reveals depressed mood with anxious affect. • Provisional Diagnosis is Borderline Personality Disorder.

HISTORY OF PRESENT ILLNESS Contd…

3rd session 7th session

11th session 12th session

We find a journey of an introvert, resentful, intelligent client. Ms. CK from her withdrawn shell to the outer compartments of colorful creativity with a strong craze for autonomy

SELF REPORT BY THE CLIENT

First session: 01.08.13 & Last session: 27.02.14, Total sessions: 12

“My first day at DANA was 1st August 2013. At first I was not willing to go for this Art Therapy. Some unfortunate incidents in life had demoralised me and I had lost all hope of recovery. But still I went for this therapy on being urged by my parents and my doctor. On the first day when the therapist encouraged me to draw and paint according to my own free will so I stopped thinking about what to draw and just let my hands do the work….and there I was ready with my first drawing. Previously I had no interests or hobbies and very little self confidence and used to have little control over feelings that were overwhelming me. Then I decided to give art therapy a try .Once a week I went for art therapy.Gradually I started gaining interest in drawing and painting. Using my imagination and colours of my choice to create whatever I wished made me feel good inside. The Art Therapy has enabled me to gain a degree of self confidence and control within the situation, a feeling of empowerment. This degree of control has also greatly decreased stress, as I have been able to find a method of escape from the potential feelings of disempowerment. I have been able to maintain a sense of self control, recognizing the ability to create whatever I may desire without any interruptions and limitations placed on my expressions. While undergoing this Art Therapy I have also met with moments of self discovery and emotional realizations.”

“The deeply held internal emotions have been distinguished and have become apparent. Art Therapy has helped me to open up, make visible my thoughts, feelings and perceptions through drawing and painting. I have been able to calm down from anxiety, and now I feel free to express and share difficult feelings. The Therapy has boosted my self confidence level and has helped me to alleviate and resolve conflicts. Thus Art Therapy has helped to rebuild my sense of hope, self-esteem, autonomy and competence while offering opportunities for safe and contained expression of feelings. Today I am a very changed person from what I was before.”

IMPRESSION: is quite evident from the self report with a sense of well being, better expression, reduction of anxiety.

SELF REPORT BY THE CLIENT Contd…

CONCLUSION

• We emphasized on the process, not on the product. However the end-product was almost always revealing and had significant positive impact on the mind of the client.

• On the basis of the content of the self report it might be concluded that the process of making the drawings has helped the suffering person to become mentally healthy at least to some extent.

• A sense of subjective well being in the clients was experienced.• Question of quantification does not arise mainly because of

paucity of data as per design followed in the present investigation.

• Overall improvement noted in all cases discussed.

LIMITATIONS

• The interpretation is based primarily on qualitative analysis.• The limitations of the methods used here are common with

the qualitative approach of a study for evaluating human behaviour. Document Analysis approach of the qualitative method may be categorized with respect to the final product which may be placed under Document Analysis . It has some similarity with Narrative Analysis where the investigator tries to understand the meaning attached to the experience of the subject. Self reports have been used for Narrative Analysis.

• Quantitative analysis needs to be done to establish the effects more categorically.