Arf Therapy: Journal of fhe American Associotion, l6(l) @ pp, 3l-36 AATA, lnc, .l999

Pointing A Poth of Well-being: Art Theropy os o Link toMentol Heolth TreotmentPotricio Jo Pendleton, MA, LPC, CAC lll, Denver, CO

Abstroct

Engaging people in treatment i,s a primar"t:/ concern at acomnutnity outpatient day treatment program sensing 280

adults uith seDere mental illness and chemical dependencies.

Goals include stabilizing one't lifu in orcler to remain out ofthe hospital and gaining skills to liue more independently.The imrned,iate focus is directed tousards monitored mecli,ca-

tions and attendance at the u,eekdall program that prouidesbreakfast, lunch, ancl a uarietu of eclucational and therapeu-tic groups and acti,uities. The art therapll progratn consists ofttuo u:eekly groups, a gallery fo, exhlblting client arttoork,ancl a quarterly newsletter fo, sharing art aniL uriting pro-&rced by the comrTurni,ty. Aft therapy has proDen to be astrongltnk to treatment for manu indlulduals and fosters sta-

blllty that uill pa:)e the usau,l to a greater sense of well-beingand success in achieaing greater independence. Case mater-ial from one consumer of this program is presented in the fol-lou;ing discussion.

lntroduction

Art therapy in community mental health treatment offers

people with severe mental illness a path of well-being that islinked to an array of necessary treatment services. People withsevere mental illness, such as schizophrenia, bipolar disorder,

and major depression, often struggle for years to accept thereality of their illness and seek appropriate treatment. Theyare in and out of hospitals and frequently use substances toself-medicate their symptoms. This unstable lifestyle leads toisolation and estrangement from their communities. Familymembers may attempt to help, but often become fnrstratedwhen their efforts are not successful.

Individuals are referred to this dual diagnosis treatmentprogram when severe mental illness and/or substance abusehas led to hospitahzation, homelessness, or legal problerns.Most individuals starting out at the day treatment programare in need of medications, substance abuse treatment,housing, and benefits. If an individual with severe mental ill-ness can become engaged in consistent treatment, a newsense of stability is discovered. Acceptance of the mental ill-ness is the first step toward the rehabilitation process. Keil(1992) notes that once people accept the diagnosis of men-tal illness they realtze that they are now citizens, not tourists,in the kingdom of mental illness.

The problem is, without a passpoft it is difficult to travel this newland with its new language, new customs, and very foreign cul-ture. The passport comes in the form of information, education,

advocacy, and adaption to individual needs. One only need navi-

gate the rnaze that will lead to the path of recovery' (p. 154)

Bachrach (1993) identified nine essentials for successful

rehabilitation of people with severe mental illness:

f. individualized treatments2. environmental adaption3. a focus on client strengths4, an emphasis on restoring hope5. optimism about the individual's vocational potential6. a range of comprehensive services-l l.t. cnent-consumer involvement in the treatment

process8. continuity of care9. a therapeutic relationship between the client-con

sumer and caregiver.The following discussion will address a community

dual-diagnosis duy treatment center that aims to providethese services; an art therapy program that supports the

goals of treatment; and a case study of a 36-year-old manwith schizophrenia who is recovering after an unstable 15

years living with mental illness.

Doy Treotment

Psychiatric rehabilitation for people with mental illnessand substance abuse is increasingly focused on assessments

and interventions to provide clients with medications, s)mlp-

tom management, counseling, and skills leading to moreindependent living (Nikkel, f994). This duy treatment pro-gram is open daily to address the needs of this population byoffering showers, laundry facilities, free clothing, breakfast,and lunch. "Outreach and drop-in center services providethe much needed first inrritation to return to indoor living"(Backlar, 1994, p. 137). During recent years, the programhas expanded the drop-in atrnosphere to include a widerange of treatment services.

This treatment center seryes 280 individuals andemploys three nurses, three psychiatrists, eight case man-agers, two mental health therapists, and one mental healthworker. The core of psychosocial treatment is providing eachmental health consumer with a case manager who assists

with basic needs such as housing, income, food, clothing,and medical attention (Backlar, 1994). In addition to basic

needs, an individual is encouraged to discontinue use ofharmful and addictive substances in order to begin a trial ofantipsychotic or mood-stabilizing medications. Individualsare offered individual counseling and encouraged to attendeducational or therapeutic groups addressing mental health,substance abuse, daily living skills, art the rapy, recreational

3r

PAINTING A PATH OF WELL BEING32

activities, and vocational rehabilitation. The- goal of this

treatment program is to prevent hospitalizations and

empower indiviiuals to live as independently as possible'

Wh?ther that means living in a group home or an apartment,

the aim is for each p"rrJn to find a life that holds greater

meaning.

Art Theropy

"Expression is a need of the human tpiltj.rather than a

tool for^revealing patholog,z" (McNiff, 1997). Prinzhorn's

(Lgzz) publicatioir,^Arti,strl' of th? Mentally lll, describes a

model that notes our hrrman iendency to express in distinc-

tive ways, such as imitative cop)nng' illustration, writing'

ornamentation, pluyfrlness, uttd -sacred

symbolic (p' 14)

providing an ur"i." where individuals in a treatment settittg

may "*pior"

their natural expressive needs offelt u p-ath of

*"it-u"lng. podvolt (1gg0) ,i"rt to "islands of clarity" with-

in each m-entally ill person (p 5l Thus, art therapy is a place

to honor and ,rlrtrrie this health within people with severe

mental illness.The art therapist at this community duy treatment facil-

ity is also u *"rrtiul health thgl?pist with a caseload of 22

inaividuals. Two one-and-a-half hour art therapy groups are

offered each week. A maximum of six people may participate

in each group due to room sLZe, buf the format is drop-in

;p"; strr?io. it ,"r"ly occurs that anyone is turned away' A

core group of about 10 individuals participul". t"gularly and

new iarticipants are always enco,triged a: visit the group'

While tfr" format is open studio, the art therapist is

engaged with each p"rror, fo assist him or her in choosing

*o:t#d, and proleits. Drawing, painting, and collage j"p-plies are u.ruilubl", as well as .tuft Pro:9c1s and clay' Cane

ifgSg) wrote of the integrative capacity of the 1tt g"perience'

She explains how hrrfrur beings "pPt+end

their world

,fr-"gfi three functions: movement' feeling, and thought'

The ""ti"ity

of artmahng involves a person in these three

areas of frnctioning. Catie promotes utt "dncation

as a key

ingredient in "rr"orr-raging^

a person to gain the most from an

uri ""perience.

Allowiirg -Ft

utt "*perience

of greater accom-

plishment pavesthe *at for a person in treatment to perceive^himself o, L"rrelf in a new *ay and possibly link that positive

experience to the entire treatment experience.

The environment of the art therapy room also con-

tributes to treatment goals. Audiotapes of instrumental

music ur" ptuyed duringirt therapy g1oup. fome would pre-

fer rock urra r.o[, but most come to rely on the relaxed music

to set the-r,ug"'for the creative process. While producing

artwork and &uft projects gives lmmediate pleasure, com-

munity members ulro ur" motivated to confribute art and

writing to be published in a qu-art"lly newsle,tter and to pro-

duce u'Uoay of *otk that mry be shown at the day program

art gallery.

Cose Moteriol

JR is a 36-year-old man who experienced the onset of

,"hiiophrenia drrring the late teen years.. He attempted to

t"girr;ril"g" and f.3p:9 to study music but due to the ill-

,r"3, droppZd out ur^d began,diifting from p119" ,to place

until l"rrdirrg in Denver a ti,tmber of years ago' He has a sis-

ter and father who are in touch with him regularly' IRappears to have no real friends'I r

]R has been in treatment with this mental health agency

fo, u f"w years. The chart shows a history of hospttartzations

and near apartment evictions due to extreme acting- out

around delulsions and hallucinations. Backlar (1994) explains

that "the person with schizophrenia is bombarded !I inter-

nal *"rrig", that have no connection to the real world'

These internal stimuli may take the form of mochng voices

or belief that others ur" "orrtrolling

the individual s thoughts"

1n OZ). Throughout these years, fn a"ttied havi"g ? mental

iilness and ,.ur8ly took *"di"utions. He used alcohol to self-

medicate his symPtoms.In Fall tsioO^1n was hospitalized and legally cerLifted to

attend treatment and take medications prescribed by his p:y-

chiatrist. His case manager referred him 1o art therapy srn3.e he

was not interested in att6n&ttg any other group' He was able to

stop the use of alcohol without substance abuse interventions.

IR began art thet?P/ with great reluctance. He pace$

the roo* urrJ explain"d ^thut it is i"*posible for him to sit still

lorrg enough to do anything WrJh some coaxing IT,t"! down

uriselect6d papet uttd coJored pencils. He scribbled some

musical notes'u"a words that he said were songs, but qujck-

ly iold"d ttrese up 1nd slipped them into his pocket. He then

dr"* a planet d blue u"d^ green on white paper. While he

hud ro ""planation

for his iriage, ,lit view ol earth from afar

suggest, fnt distance from tlie affairs of everyduy life' T:t"fiEu,"dty *ude comments about having no talent, but jR

dii seem-pleased with his efforts'

JR has continued to attend art th-erapy regularly since

his start 7 months ago and has created *ote than 75 draw-

ings and paintings "during this^.time. He has been quite

ftEur"a #h the Jffectiveriess of his psychiatric medications.'E"cept for frequent drowsiness during the

. first several

*ortir, IR is abie to imagine recoY"ry ut-:.t?d possibili'y:,

The art experience is"now tied into IR't feeling of well-

being. He fr"q,r"ntly mentions his enjoyment of the art

experience. Tire range of IR't *otk shows many of

Prinzhorn's (Ig72) h,rrriut teniencies for ex-pression' An oil

p"r,"r in the style prinzhorn referred to as illustrati,on shows

the "Moonl"iai"g" that seems to reflect-|Rs sense of land-

ing on a new terraii (Figure r). Another iliustration of a col-

orful butterfly with *tt?t spread wide suggestt ]R: t"ld"g

flight with crluti"ity (I'iE rrd 2). At the same time, this but-

teifly is a sign of transfoimation as IT: effective medications

allow him t[ feel fewer symptoms of his mental illness.

While ]n ptoduced his "^'ly

pictures ?i his owrl' he

seemed to be at aloss for ideut uit"i that and began loohng

through ^ugJines

for ideas. After selecting a picture o{ a

bi.y.lZ to use as ? guide, jR rendered his own version that

showed he was able"to express a suqprising level of shll using

i,mitati,tse copying (Figut" S). Returning to his love of music'

he found guitar image, tt 4 t ept him busy with several draw-

ings (Figure 4). IR_gradually 6""ame more confident in his

*"trtay tJ creat" u"diegan using watercolor paints to depict

his intelpretation of ,."ii. ^ugirr"" plgtos (Figures 5, 6,7)'

ts ptayfulnesswith paint J*"tg"dlltyis willing to col-

Iaborate with the art therapist (Figrir. S)r This exploration of

possibilities led |R to create a series of paintingy using an

ornamt";;i ufpiou"tt in abstract paintings of black and

vibrant color that are lovely to ,"" 6t't do not offer enough

PENDLETON 33

Figure I JR, "Moon Londing"

t;ra.t

Ir)

IO,

7a rO" (a

-J -1(. l^r-Dl

-b:

Figure 2 JR, "Butterfly"

contrast for black and white reproduction.

IR switched back to colored pencil as he expressed adesire to draw detailed pictures of animals. Shown here is aselection of large cats (Figure 9) and a selection of birds(Figure t0). when IR was asked which animal he wouldchoose to be, his reply was the seahorse. "That way I'll beleft alor€," he explained.

During these months of art therapy, JR showed

Figure 4 JR, "Three Guitors"

Figure 3 JR, "Rough Drowing of o 10 Speed"

Figure 5 JR, "Field of Flowers"

34

Figure 6 JR, "Flowers"

Figure 7 JR, "Jungle"

increased confidence in his interactions with others. He even

broke into a Beatles' song, "Blackbird singing in the dead ofnight...," after completing his drawing called "Raven."

Winnicott (1971) explains how art objects become "other, yetnot other

- self, yet not self' and offer healing as "transi-

tional phenomena" (p. 50). IR't wildlife pictures served as

transitional objects and provided healing as he gainedstrength from knowing his creations.

jR includes his full name, date, and descriptive title on

PAINTING A PATH OF WELL BEING

Figure 8 JR, "Colloborotion"

Figure 9 JR, *Young Tiger""Leopord Kicking in Dust""Tiger"

many of his pictures. He moves beyond the concrete titles ofearlier works with his picture of sun and moon over moun-tains (Figure lf ) with a poetic use of words: "The slq'2, yousee forever. The sun, you have soul." This grounded expres-sion illustrating Prinzhorn's writing tendency shows that ]Ris living more fully in his environment. McNiff (1997) con-firms this with a discussion about how people express them-

PENDLETON 35

Figure l0 JR, "Porrot" "Bird" "Roven"

Figure I I JR, "The Sky, You See Forever.The Sun You Hove Soul,"

selves atrthentically when they come to life and interact withtheir environment. The artworks they produce are rein-forced when exhibited, contributing yet another cycle oftherapeutic affirmations. Art therapy participants at this pro-gram experience this second level of self-esteem rvhen theysee their work hanging on the artroom walls or printed in theduy program newsletter or exhibited on the walls of the duy

program gallery.

IR't symptoms of schizophrenia are managed well now.

He has indicated that certain delusions remained fixed, buthe rarely mentions these and is not outwardly focused on

these delusions. JR is no longer legally certified to receive

treatrnent and he is able to reco gnize that voluntary partici-

pation is beneficial. He is able to live a rnore meaningful life

Ly taking good care of hirnself. ]R has achieved stability that

uilo*, ffi to maintain a nice apartment, prepare food,

engage in enjoyed activities, and interact more effectivelywith others. This recovery to a better quality of life is possi-

ble through an ongoing participation in treattnent.

Conclusion

People with severe mental illness benefit from a com-

munity lreatment prograln that offers a wide range of ser-

vices. Sy*ptom management combined with case manage-

ment and therapeutic interventions encourages a person

with severe men[al illness to a rnore stable lifestyle. A treat-rnent program that provides creative opportunities allows

consumers of rnental health care to paint their own paths ofwell-beitrg.

Art the rapy supports a mental health care environmentthat ernphasiies rehabilitation and recovery by offering an

irnmediate experience of competence and skill developtnent.

This increas"d t"ttse of well-being may encourage the con-

sumer to becorne more strongly linked to the array of ser-

vices and treatments that lead to recovery. Art therapy offers

a positive experience of creative self-expression that rein-foices a positive experience of treattnent compliance.

References

Backlar, P. (f994). The farnily face of schizophrenia: Practical coun.sel

Jrom Arnerica's leoding exyterts. New York: J.P. Putnatn'.s Sons.

Bachrach, L. (1993). Continuitl, of care and approarches to case mtlnage-

rnent for long-term rnentally ill patients. Hospitals {, Comrrrunity

Psy chiatry, 44, 465-468.

Bindeman, S. (1996). Schizophrenia and postrnodern philosophy. The

Humanistic P sq cholo gist, 24(2), 263-282.