Psychotropic Medication and Art Therapy: Overview of Literature and Clinical Considerations

The Arts in Psychotherapy 38 (2011) 29–35

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The Arts in Psychotherapy

Psychotropic medication and art therapy: Overview of literature and clinical considerations

Charleen Dere-Meyer, MA ∗, Brooke Bender, MA, Einat Metzl, PhD, Kathryn Diaz, MA

Loyola Marymount University, College of Communication and Fine Arts, Marital and Family Therapy Department, One LMU Drive, Los Angeles, CA 90045, USA article info abstract

Keywords: This paper reviews literature regarding psychopharmacological treatment options for ADHD, depression Psychopharmacology and dual diagnosis, and explores perceptions of treatment and considerations for art therapy in con- Art therapy junction with psychotropic medication. This review attempts to initiate discussion and propel further ADHD research in the expressive arts ﬁeld regarding the growing need to conceptualize our understandings of Depression the role art therapy plays in combined treatment with psychopharmacology. Dual diagnosis © 2010 Elsevier Inc. All rights reserved.

Introduction medication choices and treatments are common. We examined the art therapists’ role in helping clients explore the multiple layers Research in the field of art therapy relevant to psychotropic of their needs (psychological, psychiatric, behavioral, etc.) and the medications seems to be lacking, while the use of medication for meaning of their treatment choices through art interventions. most clients is high and on the rise (Barbui & Tansella, 2005). Due to the popularity of medication treatment, it is imperative that art Depression therapists research the role of art therapy and identify the poten- tial benefits to clients with whom psychiatric interventions are Art therapy may also be useful in discussing medication-related likely. The limited research findings regarding medication in our choices for clients suffering from depression. Approximately 9.5 field suggest that art therapy can be a valuable tool to measure percent of the United States population suffers from a mood disor- psychotropic medication effectiveness (Epperson & Valum, 1992; der, including major depressive disorder, dysthymic disorder and Munley, 2002), and that implementing art therapy in conjunction bipolar disorder (NIMH, 2008). The primary features of a major with medication treatment can reinforce positive skills, which can depressive disorder include depressed mood, diminished interest enhance the effects of medication alone (Rosal, 1993; Saunders & or pleasure in most activities, weight loss or weight gain, insom- Saunders, 2000). Furthermore, art therapy seems to be a sensitive nia or hypersomnia, psychomotor agitation or retardation, fatigue, form of communication that can assist individuals with explor- feelings of worthlessness or inappropriate guilt, inability to con- ing their perception of medication treatment in a non-judgmental centrate, and thoughts of death or suicidal ideation (DSM-IV-TR, manner (Branch, 1992; Westrich, 1994). 2000). This paper is a collaboration of research based on the final Antidepressants are commonly used for the treatment of research papers of five students from the Clinical Art Therapy and depression (Howland, 2007; Preskorn & Ross, 2004; Preskorn, Ross, Marital and Family Therapy graduate program at Loyola Mary- & Stanga, 2004), although many researchers have found the com- mount University and their research mentor. We attempted to bination of cognitive behavioral therapy and antidepressants to be explore relevant literature and have provided two case illustra- the most effective treatment (Emslie, 2006; Vitiello, 2007). Art ther- tions where art therapy offered a unique exploration into clients’ apy has been found to be beneficial in the treatment of depression; choices and struggles, especially within the context of treatment on for example, it may allow individuals to express aggression in a psychotropic medications. Specifically, we focused on the impor- safe manner (Branch, 1992), which can lead to catharsis of destruc- tance of understanding medications and overall treatment choices tive impulses (Evans, 1986; Grodner, Braff, Janowsky, & Clopton, for clients suffering from depression, dual diagnosis and atten- 1982). Furthermore, the creation of art is a non-intrusive way to tion deficit hyperactivity disorder (ADHD), – three disorders where communicate and is less threatening than only verbal interventions for individuals who have difficulty verbalizing their emotions (Harnden, Rosales, & Greenfield, 2004). Thus, art therapy has been ∗ found to be useful in increasing a client’s communication regarding Corresponding author at: P.O. Box 1411, Torrance, CA 90505, USA. Tel.: +1 310 567 4878. depressive symptoms. The integration of psychotropic medication E-mail address: [email protected] (C. Dere-Meyer). in treatment adds an increased need for effective communication.

Fig. 1. Untitled.

Art therapy may be useful to increase communication between the processing the effects of using or not using medication to improve client and treatment team members to assist in successful medica- her mood and everyday functioning. It also allowed the client to feel tion treatment. safe enough to disclose her past history of suicidal ideation and self One of the writers of this paper, Bender (2009), conducted a injurious behavior that she had not previously disclosed during the case study regarding psychotropic medication treatment and fam- intake session or thereafter. ily communication patterns in art therapy treatment and noted The creation of art was also used to facilitate communication the importance of understanding art therapy in conjunction to between mother and daughter, in the hopes of diminishing any anx- medication treatment. “Amanda”, a 38-year-old African American iety that Amanda’s daughter, Sasha, may have had about Amanda’s woman in family art therapy treatment, was taking the antidepres- medication treatment (Fig. 2). Amanda used a brown colored pencil sant Prozac for her diagnosis of Major Depressive Disorder with to draw images of herself and Sasha with the word “talking” placed Psychotic Features. Amanda referred her daughter, the initial iden- between them, and a house placed beside the figures. The figures tified patient (IP), for treatment, but throughout the course of family are not facing each other, but instead appear to be facing out into the treatment Amanda’s depressive symptoms increasingly took prece- distance. The figures are not colored, have a small amount of detail, dence. and are not placed on a solid ground line. The entire image is float- After one month of taking Prozac, Amanda disclosed to the ther- ing at the top part of the page. According to the Formal Elements apist that she “ran out” of her medication, in spite of the therapist’s in Art Therapy Scale (FEATS), a scale that attempts to standardize observation of increased positive affect. In an individual session one the use of art therapy as an assessment tool, a lack of detail and and a half months later, Amanda created a collage that explored little or no environment may be related to symptoms of dimin- how medication was/was not beneficial to her (Fig. 1). The image ished interest or diminished ability to think or concentrate (Gantt on the left, according to Amanda, depicts what she felt like when she was not taking antidepressants. The young stone figure, holding a mask or face of an older man, represents a feeling of having multiple personalities (although she said they are not different people) and hearing voices in her head. Amanda admitted to experienc- ing shame in response to hearing these voices, with whom, she explained, she felt she was battling. She stated that when she is not taking medication, she feels angry and overwhelmed, easily irritated, and has difficulty controlling her response to situations. The sharp, jagged edges of the collage image with the mask is a stark contrast to the more visually balanced, rectangularly shaped collage image on the right. The image on the left overwhelms the page, and one may hypothesize that there is a relationship between this image and the client’s feelings of overwhelming anxiety and irritation. Amanda stated that when she takes medication (as indicated by the image on the right, Fig. 1), she cries less, is less irritable, has increased focus, and is able to make decisions more easily, as opposed to when she is not on medication. The art intervention, as described above, facilitated communication regarding medication between the client and therapist, and perhaps assisted the client in Fig. 2. Talking. C. Dere-Meyer et al. / The Arts in Psychotherapy 38 (2011) 29–35 31

Fig. 3. Before and after.

& Tabone, 1998). That impression obtained from her art echoed Many dually diagnosed individuals self-medicate with sub- Amanda’s verbal indication of difficulty focusing when not taking stances to manage the symptoms of their mental illness, which medication. This could be seen as an example of how client’s art- can eventually lead to abuse and addiction (Magura et al., 2003). work could help clarify and affirm challenges the client is facing Options for mental health interventions are limited, as the majority beyond subjective concerns. of drug rehabilitation programs look down upon the use of psy- When asked to explain the picture, Amanda said, “This is me and chotropic medication due to their 12-Step model philosophy, which Sasha talking about me taking medication.” During this session, often does not approve of medication use during recovery (Jordan, Amanda stated that Sasha did not know she was taking medica- Davidson, Herman, & Bootsmiller, 2002; Magura et al., 2003). Many tion, even though she was present when she said this. Although the treatment programs insist that a patient with a co-occurring disor- art did not necessarily open communication between mother and der should not be treated with psychotropic medication until they daughter, it provided the therapist with useful information about have been in recovery for at least one year (Zweben & Smith, 1989). Amanda’s discomfort about discussing medication with her daugh- Recovering individuals are often at odds with taking medication, ter. Amanda later disclosed that she did not feel comfortable talking due to the fact that psychotropic medication is still seen as a “drug,” to her daughter about her medication because she did not want her and that they are unable to recover on their own, without the use to worry. This might have been an important factor in her decision of medication (Zweben & Smith, 1989). However, medication is to stop taking medication, consciously or sub-consciously, as she often crucial in effective treatment of dually diagnosed patients, as may have felt uncomfortable or shamed by her medication use. it helps control or adjust chemically imbalanced emotional states Art therapy seemed to be a useful tool to assist Amanda in fur- and psychotic symptoms. Thus, if one suffers from addiction and ther exploring medication treatment and her possible feelings of mental illness, treatment is complicated by the multiple and, at embarrassment as well as worry about disclosure of medication times conflicting needs of clients, which challenge both patients use. The art seemed to help the client explore some feelings of and clinicians (Aase, Jason, & LaVome Robinson, 2008). embarrassment over her mental health diagnosis and medication Art therapy can be a valuable form of treatment for dually diag- use, as well as shame of having hallucinations. Art therapy’s ability nosed patients. Often times, patients have difficulty with verbal to improve self-esteem (Ponteri, 2001) in a non-judgmental man- expression, which may be impacted by mental illness and the ner (Branch, 1992) could have addressed Amanda’s symptoms of emotional and physical toll of severe addiction (Taylor, Kymissis, depression as well as stigma of psychotropic medication treatment & Pressman, 1998). Art is also a sensitive, non-judgmental tool if treatment had not terminated prematurely. that allows presentation of complicated and multiple issues. Many clients diagnosed with both addiction and mental illness struggle Dual diagnosis with the added layer of complexity, as stigma regarding their illness and self-soothing or treatment choices is met with further judg- A second population for which medication might play a preva- ment (for example if he or she joins an AA group and still decides to lent role is with dually diagnosed clients. According to Mental take psychotropic medication for depression or anxiety). Art ther- Health America, an official online organization, 37% of alcohol apy, therefore, might offer an alternative form of communication abusers and 53% of drug abusers suffer from at least one mental for the mentally ill individual who is also compounded with the illness (nmha.com, retrieved December 2, 2008). While the DSM-IV- problems surrounding addiction. TR (2000) contains criteria for substance abuse disorder and mental For example, art therapy was found to be a very useful tool illness, it lacks an actual definition of the term “dual diagnosis.” in working with “John,” a 39-year-old Caucasian male who was a Nonetheless, the term “dual diagnosis” is used to refer to those suf- resident at a Los Angeles based drug rehabilitation center. John’s fering from the coexistence of one or more mental disorders and a treatment was the focus of a case study conducted by Diaz (2009). substance use disorder (Todd et al., 2004). John had been admitted several times to both psychiatric units and 32 C. Dere-Meyer et al. / The Arts in Psychotherapy 38 (2011) 29–35

Fig. 4. On medication vs. off medication. rehabilitation programs, but this was the first time he was offered therapist, the creation of art allowed him to identify and begin to psychotherapy within a rehabilitation center. At the time of intake, process these contrasting states. John was taking antipsychotic and antidepressant medications. Accordingly, art therapy can help the dually diagnosed individ- In art therapy treatment, John was verbally guarded and had ual distinguish between the two diagnoses, explore the impact and a difficult time discussing his bipolar diagnosis. In sessions, he meaning of dual diagnosis, and eventually attempt to merge the focused mainly on his addiction and seemed less comfortable iden- two contrasting identities into one, helping to provide self- accep- tifying himself as dually diagnosed, perhaps due to the stigma of tance through understanding. Johnson (1990) states that creativity mental illness that he experienced. In reviewing his case notes and in itself might provide remedy for shame, which may be experi- artwork, Diaz noted that he consciously represented his addiction enced by many suffering from both addiction and mental illness. (by verbally naming his pieces), while subconsciously he clearly This attribute seemed inherent in John’s experience of “not being represented his mental illness. For example, in John’s first art ther- normal.” Julliard (1995) suggests that if one’s understanding of apy session, he created a collage that illustrated his “two parts,” his/her denial deepens, whether it is the denial of addiction or men- which allude to a dark side and a lighter side, an inebriated side tal illness, he or she can have an enhanced grasp on the disease and and a sober side, and presumably, a manic side and a depressed side a better chance at maintaining sobriety. (Fig. 3). As treatment progressed, John would continuously discuss Although John may have been influenced by the 12-Step model his addiction verbally and his efforts to stay sober. He attended AA to cease psychotropic medication treatment for his mental illness, meetings and had a sponsor, but refused to acknowledge his bipo- his drawings and his symptoms suggested that he benefitted from lar disorder or discuss it. His artwork, nevertheless, continued to the medication. His ambivalence could therefore be further pro- manifest dichotomist experiences and he seemed more and more cessed in treatment. This case illustration suggests that it might depressed. The gap between his addiction and his bipolar diagnosis be crucial to understand the complicated and conflicting mean- grew wider and perhaps illustrated a growing disparity between ings of medication and recovery for dually diagnosed clients. It also the accepted and conscious parts of himself and the disowned, suggests that art therapy could be particularly useful in exploring subconscious part. the duality of these diagnoses, along with the use of medication, It seems as though the underlying emotional experience of these in a safe and creative setting, addressing the layered and difficult two sides was very frustrating and confusing for John, as he was decisions in a less threatening fashion. unable to reconcile them or bridge them. Throughout the process of art therapy, he became more aware of the existence of these two Attention-deficit/hyperactivity disorder (ADHD) sides of himself, and was able to identify them as “two separate entities of his personality” (Diaz, 2009). Nevertheless, the confu- Another disorder for which medication is part of standard sion, frustration, and inability to reconcile these two parts resulted mental health treatment is attention-deficit hyperactivity dis- in John’s growing identification as an addict, and the eventual deci- order (ADHD), and one that many of our art therapy clients sion to cease psychotropic medication treatment. suffer from. ADHD is currently the most common psychi- John admitted that being on medication was seen as a “crutch” atric diagnosis in children (DSM-IV-TR, 2000; Furman, 2005; to his recovery in his 12-Step program, and added that he just Richters et al., 1995). According to the DSM-IV-TR (2000) the wanted to be “normal,” and not “dual-diagnosis or whatever.” It disorder is characterized by patterns of inattention and/or hyper- was quite likely that the stigma of psychotherapy, medication, and activity and impulsivity that occur more frequently, and it mental illness within the 12-Step recovery program affected him appears to be more severe than in individuals at compara- and interfered with his ability to accept or process his mental illness tively equivalent developmental stages. It is associated with diagnosis. As he was making this choice, art therapy was utilized low self-esteem as a result of consistent academic failures to explore the client’s perception of medication treatment (Fig. 4). and impaired familial and peer relationships. There are three Fig. 4 presents a drawing illustrating “what it felt like to be med- subtypes within ADHD: predominately inattentive type, predomi- icated versus what it felt like to not be medicated.” While John nately hyperactive-impulsive type, and combined type. Diagnostic felt uncomfortable verbally discussing these experiences with the requirements for ADHD in DSM-IV-TR (2000) state that the symp- C. Dere-Meyer et al. / The Arts in Psychotherapy 38 (2011) 29–35 33 toms should be present in at least two settings for a minimum of expressive qualities in the artwork and medication response. Sub- six months. jects who displayed decreased behavioral symptoms as a result of Richters et al. (1995) claim ADHD to be one of the most treatable effective stimulant treatment created artwork that displayed less childhood mental disorders. Psychopharmacological, psychother- scribbling and higher levels of media control, organization, and apeutic, and combined interventions are common treatment completion. methods of ADHD (Olfson, Gameroff, Marcus, & Jensen, 2003). Munley’s study (2002) supports the use of art therapy in iden- However, pharmacological treatment, specifically stimulant medi- tifying symptoms of ADHD in children. Munley used the Draw cation, is considered to be the most popular among parents due to a Person Picking an Apple from a Tree (PPAT) test and mea- the cost efficiency, in addition to the pressure for them to quickly sured expressive qualities using Gantt’s Formal Elements Art reduce symptoms (Jensen et al., 2005). Therapy Scale (FEATS). These rating instruments were used to com- Research presents ambivalence among caretakers towards the pare the art work of boys diagnosed with ADHD who were not use of stimulant medication in the treatment of ADHD. Although being treated with psychotropic medication and a control group stimulant treatment is the most widely used intervention, par- without any learning/behavioral disorders to determine whether ents reportedly prefer psychotherapeutic treatments because of or not formal elemental differences would be observed in the the possible side effects of stimulant medication, worry of over- artwork created between the two groups. Formal elemental differ- prescribing of medication, and the need to address behavioral ences were observed, including “less Prominence of Color,” “fewer issues rather than solely decrease symptoms (Stroh, Frankenberger, Details of Objects and Environments”, and “reduced control of Line Cornell-Swanson, Wood, & Pahl, 2008). Furthermore, according to Quality”—all formal elements found in the drawings of children Barkley, DuPaul, and Costello (1993), and Richters et al. (1995), diagnosed with ADHD. This suggests that the application of the stimulant medication has short-term effects and does not perma- PPAT and FEATS could be used to assess and confirm ADHD diag- nently improve social and emotional issues. Nonetheless, stimulant noses. Munley further predicted the usefulness of the PPAT and medication treatment is popular and commonly used, as it is less FEATS in measuring a child’s pharmacological response, while also expensive than behavioral therapy (Jensen et al., 2005). Art therapy allowing the child to participate in his or her own medication eval- can be implemented as a conjunctive treatment with medication, as uation. it can address and improve socio-emotional issues related to ADHD. Based on the literature and the standardized tools mentioned The creation of art provides a visual, permanent record of an indi- above, art therapy can be useful in the assessment, diagnosis and vidual’s emotional and behavioral experience (Epperson & Valum, treatment of ADHD, and can specifically be useful with gauging 1992; Munley, 2002; Rosal, 1993). As Safran (2002) aptly stated, medication dose and effectiveness. Art therapy may be particularly art “is (a) an activity that (b) uses what are often stronger visual useful in treating clients who suffer from this disorder because it is learning skills to (c) lend structure and (d) give people who tend age appropriate, developmentally sensitive and provides a perma- not to be contemplative a way to express their feelings in therapy” nent record that can be used throughout the course of treatment. (p. 23). Saunders and Saunders (2000), for example, found that over a three-year period, art therapy guided children towards increased Discussion and conclusion communication and expression and helped to decrease the sever- ity and frequency of negative communication and defiant behaviors In this paper we explored the importance of considering psy- in children. Rosal (1993) compared the applications of cognitive- chotropic medications and exploring the meaning of psychotropic behavioral art therapy and art as therapy with a control group treatments for art therapy clients. We identified three common over the course of 10 weeks. The outcome of the study revealed diagnoses in which psychotropic medication is often indicated that both cognitive behavioral art therapy and art as therapy had and where art therapy can promote clients’ wellness by exploring positive effects on behavior of children suffering from ADHD and symptoms as well psychological meaning of taking medications. other behavior disorders and led to increased perception of con- We illustrated two cases in which art therapy interventions trol. Rosal (1993) noted that one participant began to use art for were offered within the context of psychotropic treatment of “aggressive play,” to draw aggressive pictures, and then gradually depression and dual diagnosis. In both cases, the art making and dis- throughout time to use the art to express positive feelings, sug- cussion served as a non-judgmental tool in which clients could be gesting that art therapy positively affected the participant’s locus supported in making conscious choices regarding managing their of control perceptions. She concluded, “The act of producing art overall treatment and exploring feelings and concerns that become may reinforce or enhance internal LOC perceptions” (p. 240). There barriers to optimal treatment. The exploration of medication com- was no overall improvement found in the behavior of individuals in pliance and stigma regarding taking medication seem to be two the control group. The results of these studies suggest that art ther- major themes for clients in these cases. apy may support the treatment of ADHD and can possibly reduce We then provided psychiatric and psychological literature on the need for medication, and/or assist with ongoing evaluation and treatment methodologies for ADHD. The minimal, yet valuable, art communication of children’s needs. therapy research on ADHD and psychotropic medication suggests Treatment providers often empirically prescribe stimulants as a that standardized art therapy tools (such as the PPAT and FEATS) “diagnostic trial,” gauging the initial type and dose of medication by could be used to support ADHD treatment and research. The use the child’s weight, and monitoring regularly, often exploring differ- of art making in assessment seems to be particularly useful for ent types of medication before finding the most effective fit for the children who might struggle with verbal assessments. The use of child (Barkley, 2006; Furman, 2005). Epperson and Valum (1992) standardized art therapy tools in treatment and research of ADHD demonstrated how the application of art therapy could be used needs to be further studied in our field, and a pilot study by Dere to gauge the effectiveness of stimulant medication in ADHD treat- (2009) was one of the outcomes of this initial exploration. ment. Expressive qualities of artwork created by children receiving While research regarding art therapy treatment and medica- stimulant medication were measured using a rating scale cre- tion is lacking, there are several papers supporting the points we ated by Epperson. The rating scale assessed scribbling, control of attempted to highlight here. For example, Safran (2002) addressed media, organization, and completion, which was hypothesized to the multiple approaches to treating ADHD and the importance of be related to ADHD symptoms of hyperactivity, inattention, and working holistically and systemically to support working through impulsivity. Results of the study indicated a connection between the child’s challenges with a plethora of resources. Epperson and 34 C. Dere-Meyer et al. / The Arts in Psychotherapy 38 (2011) 29–35

Valum (1992) specifically named the effects of stimulant medi- identify as an addict was likely connected to his wish to belong cations on art products of ADHD children, and suggested that art to the community AA provides, but that affiliation reinforced the therapy could help children regulate under- and over-medication, stigma of taking medication and was thus counter-productive to accordingly. Julliard (1995) alluded to the importance of explor- his individual needs. ing identity and belief through art therapy to support chemically This collaboration suggests the need for research in several dependent patients in recovery, and Ponteri (2001) addressed the areas. Further research could be particularly beneficial in explor- need to assess depression within mother–child dyads and support ing the use of art therapy in assisting dually diagnosed individuals mothers in assuming responsibility for their decisions in seeking with addressing mental health from a holistic perspective, taking improved mental health. Stigma became a common theme among into account psychotropic medication treatment as well as avoid- research done, and it was found that almost 1 in 10 patients are ing addictive behaviors and substance abuse. As Westrich (1994) reluctant to take medication because of embarrassment associated indicates, art therapy can aid individuals in exploring treatment with the illness or treatment (Jenkins & Sajatovic, 2007). In Bender’s choices in a more comfortable manner, a decision process that can (2009) case study, the caretaker, Amanda expressed feelings of be especially complicated for dually diagnosed clients. Also, feel- shame in relation to the voices she was hearing as well as worry ings of stigma related to medication use became a common theme about her daughter finding out about her medication use. This case in all three diagnostic categories discussed, and further research terminated early, and while it is unclear exactly why medication examining the role of art therapy in this area would be a valuable treatment was also terminated, the researchers feel it is pertinent and important contribution to our field. Finally, research on the use to explore and to take into consideration shame, stigma and other of art therapy and monitoring medication use is extremely limited feelings as well as cultural perceptions about medication use. and is needed to explore the relationship between the two areas. Themes of stigma regarding medication use and mental illness We hope that this article increases awareness of the value of art also arose in Diaz’s (2009) case study, where the client, John, may therapy in conjunction with psychotropic medication treatment. have experienced these feelings, compounded by participation in a We encourage more art therapists and researchers to contribute to 12-Step program. The researcher supported the use of art therapy the limited body of knowledge in this area through further research in exploring the client’s feelings about medication use and conflict- and publications. We believe that doing so will further cultivate ing identities. For dually diagnosed individuals, 12-Step programs’ and validate our profession, as we continue to collaborate with general apprehension of psychotropic medications might impact psychiatrists, nurses and other mental health professionals. their treatment decisions, self-esteem and/or ability to maximize support systems. 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