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005. Schizophrenic Communication: Art Therapy and Language Production Karen R. Karpick
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THE FLORIDA STATE UNIVERSITY
SCHOOL OF VISUAL ARTS AND DANCE
SCHIZOPHRENIC COMMUNICATION: ART THERAPY AND LANGUAGE PRODUCTION
By
KAREN R. KARPICK
A Thesis submitted to the Department of Art Education in partial fulfillment of the requirements for the degree of Master of Science.
Degree Awarded: Summer Semester, 2005.
The members of the Committee approve the Thesis of Karen Karpick defended on June 27, 2005.
______Penelope Orr Professor Directing Thesis
______Marcia Rosal Committee Member
______David Gussak Committee Member
Approved:
______Marcia Rosal, Chair, Art Education Department
______Sally McRorie, Dean, School of Visual Arts and Dance
The Office of Graduate Studies has verified and approved the above named committee members.
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ACKNOWLEDGEMENTS
I would like to thank the following individuals for their assistance with the completion of this manuscript: Dr. Penelope Orr, Dr. Marcia Rosal, and Dr. David Gussak.
In addition, I would like to thank the following individuals for their kind support throughout this endeavor: Shae Hughes-Brand, Psychological and Family Consultants, Inc., and Dr. Martin Bohn.
A special thanks to the Statistical Consulting Center at Florida State University for assistance with statistical measures and helpful advice for future studies; however, any errors of fact or interpretation remain the sole responsibility of the author.
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TABLE OF CONTENTS
List of Tables ...... vii List of Figures ...... viii Abstract ...... x
1. INTRODUCTION...... 1
Purpose of the Study...... 1 Justification for the Study ...... 2 Research Question ...... 3 Definition of Terms ...... 3 Brief Overview of the Study...... 7
2. REVIEW OF LITERATURE...... 9
Search Techniques ...... 9 History of Schizophrenia ...... 10 History of Schizophreniform ...... 11 Visual Imagery in Schizophrenia and Schizophreniform ...... 12 Schizophrenic Disorders and Therapy ...... 14 Language Dysfunctions in Schizophrenia ...... 14 Nonverbal Communication ...... 15 Art Therapy ...... 16 Art Therapy and Mental Illness...... 17 Art Therapy and Symbolism ...... 18 The Use of Symbols...... 19 Limitations ...... 20
3. METHODOLOGY...... 23
Description of Design ...... 24 Description of Sample ...... 24 Description of Instruments...... 25 Procedure ...... 26 Internal and External Validity...... 28
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Statistical Techniques ...... 29 Ethical Considerations ...... 29
4. CASE PRESENTATION...... 31
Participant 1 ...... 32 Participant 2 ...... 40
5. RESULTS ...... 48
Measure 1 ...... 48 Measure 2 ...... 49 Measure 3 ...... 49 Participant 1 ...... 50 Participant 2 ...... 55 Comparison of Language Production Data ...... 60 Comparison of Artwork...... 62
6. SUMMARY AND DISCUSSION ...... 65
Progress of Participants ...... 65 Recommendations for Future Treatment...... 66 Theoretical and Clinical Considerations ...... 67 Interpretation of Results ...... 68 Limitations of the Study...... 69 Implications for Future Research ...... 70 Contributions to the Field of Art Therapy ...... 71 Conclusion ...... 72
APPENDICES ...... 73
A Schizophrenic Subtypes and Related Disorders...... 73 B Participant 1 Language Production Results ...... 76 C Participant 2 Language Production Results ...... 81 D Participant 1 Artwork...... 85 E Participant 2 Artwork...... 92 F Approval Forms ...... 99
v
REFERENCES ...... 105
BIOGRAPHICAL SKETCH ...... 108
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LIST OF TABLES
Table 1: Participant 1 DSM-IV-TR Diagnostic Information ...... 34
Table 2: Participant 2 DSM-IV-TR Diagnostic Information ...... 41
Table 3: Participant 1 Pre-Test and Post-Test Results 1...... 50
Table 4: Participant 1 Pre-Test and Post-Test Results 2...... 51
Table 5: Participant 1 Phonological Fluency Comparison ...... 51
Table 6: Participant 1 Semantic Fluency Comparison...... 52
Table 7: Participant 2 Pre-Test and Post-Test Results 1...... 56
Table 8: Participant 2 Pre-Test and Post-Test Results 2...... 56
Table 9: Participant 2 Phonological Fluency Comparison ...... 57
Table 10: Participant 2 Semantic Fluency Comparison...... 58
Table 11: Participant 1 Measure 1A ...... 77
Table 12: Participant 1 Measure 2A ...... 77
Table 13: Participant 1 Measure 1B ...... 78
Table 14: Participant 1 Measure 2B ...... 78
Table 15: Participant 2 Measure 1A ...... 82
Table 16: Participant 2 Measure 2A ...... 82
Table 17: Participant 2 Measure 1B ...... 83
Table 18: Participant 2 Measure 2B ...... 83
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LIST OF FIGURES
Figure 1: Hierarchy of Mental Processes ...... 22
Figure 2: Frequent Speech Errors...... 22
Figure 3: Participant 1 Scribble Drawing: Phase 1 ...... 86
Figure 4: Participant 1 Scribble Drawing: Phase 2 ...... 87
Figure 5: Participant 1 Scribble Drawing: Phase 3 ...... 88
Figure 6: Participant 1 Personal Symbol Drawing ...... 89
Figure 7: Participant 1 Personal Symbol Drawing: Detail ...... 89
Figure 8: Participant 1 Personal Symbol Sculpture ...... 90
Figure 9: Participant 1 Personal Symbol Sculpture: Detail ...... 90
Figure 10: Participant 1 Mandala Painting ...... 91
Figure 11: Participant 1 Mandala Painting: Detail 1 ...... 91
Figure 12: Participant 1 Mandala Painting: Detail 2 ...... 91
Figure 13: Participant 2 Scribble Drawing: Phase 1 ...... 93
Figure 14: Participant 2 Scribble Drawing: Phase 2 ...... 94
Figure 15: Participant 2 Scribble Drawing: Detail ...... 94
Figure 16: Participant 2 Personal Symbol Drawing ...... 95
Figure 17: Participant 2 Personal Symbol Sculpture ...... 96
Figure 18: Participant 2 Personal Symbol Sculpture: Detail 1 ...... 97
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Figure 19: Participant 2 Personal Symbol Sculpture: Detail 2 ...... 97
Figure 20: Participant 2 Personal Symbol Sculpture: Detail 3 ...... 97
Figure 21: Participant 2 Mandala Painting ...... 98
Figure 22: Participant 1 Mandala Painting: Detail ...... 98
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ABSTRACT
Cognitive deficits, including thought disturbances, have impacted the language production capabilities of individuals diagnosed with mental illnesses such as schizophrenia and schizophreniform disorders. This research study explored the language production capabilities and the artwork of individuals diagnosed with schizophrenia and schizophreniform disorders. This study utilized previous research on the language production of individuals diagnosed with schizophrenia by Goldberg, Aloia, Gourovitch, Missar, Pickar, and Weinberger (1998). Specifically, the researcher used the instrumentation for the measures of verbal fluency testing, which include measures of phonological and semantic fluency, from the aforementioned study to gain insight into the language production differences between schizophrenia and schizophreniform disorders. This research study addressed the question: Can the introduction of symbolic art therapy increase the verbal and symbolic output of adult psychiatric patients diagnosed with schizophrenia? This research study used a quantitative analysis of data addressing change in the production of language as measured by verbal fluency testing, as well as a quantitative analysis of spontaneous speech of the participants and the artwork produced over the course of a four week period. Two individuals from a southern psychiatric clinic with a DSM-IV-TR diagnosis of schizophrenia and schizophreniform disorder participated in the study. Artwork was created during a series of four art therapy sessions that focused on symbolization. Neither participant showed conclusive or significant change over time from the pre-test and post-test verbal fluency measures. However, the artwork revealed a progress in both participants in the ability to use symbols in artwork. This result implied the need for further research assessing the differences of language production between the two disorders.
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CHAPTER 1
INTRODUCTION
Introductory Statement
The National Institute of Mental Health (2004) stated that schizophrenia is a mental illness affecting approximately 1.1% of the population (ages 18 years and older). This amounts to more than 2.2 million Americans. Schizophrenia is an organic brain disease that may leave a person disabled cognitively, mentally, and emotionally. Schizophreniform disorder is a subtype of schizophrenia, marked with a shorter duration of active symptoms (lasting at least a month but no longer than six months). In schizophrenia, gender differences are equal between men and women, although the onset for men is usually earlier than for women. Many individuals suffering from schizophrenia are admitted to psychiatric facilities where treatment and support are offered to help clients reach an adequate level of stability to successfully re-enter the community.
Purpose of the Study
This study attempts to ascertain insight into the relationship between art therapy and language production in adult psychiatric patients diagnosed with schizophrenia. The thesis is that art therapy will prove to be a beneficial method (as it may prove to be a less threatening communication modality) of increasing language production in individuals suffering from the disabling cognitive effects of
1 schizophrenia. Art therapy may be an effective method of communication between client and therapist in the relay of what the client is experiencing while in a schizophrenic state of mind. Investigating the possibility of a link between visual and verbal modalities may lead to further implications in the research on schizophrenia and the efficacy of art therapy. Additionally, the purpose of this study is to encourage future research on this topic. The concept of a connection between verbal and nonverbal communication is one that is inferred, to research and find an actual relationship would further support the use of art therapy, as well as introduce a new mode of communication to persons with mental illnesses.
Justification for the Study
Promoting awareness of the values and benefits of art therapy is essential for community, state, and country to utilize art therapy services in a variety of settings. This study gives an example of the value of art therapy as a means of eliciting a less intimidating communication style between client and therapist. The data obtained provides therapists with valuable information on the capabilities of language production and its relationship to art making in persons suffering from schizophrenic disorders. Wilson (2001) stated that symbolism and the ability to create symbols are formed concurrently with the development of ego functioning. Yet, an individual suffering from a schizophrenic disorder possesses a dysfunction in symbol formation and a disturbance of the reality functioning of the ego. This correlates to language production; in order for higher mental processes to execute, such as language, a healthy ego function must be developed. Wilson’s research is based on the belief that “making visual images helps patients with defective ego functioning and impaired symbolization develop the capacity to symbolize, an ability fundamental to almost all civilized functioning” (p.53). Thus, art therapy provides the individual with the ability to symbolize, which then leads to a more complex mental representation of language and language production.
2 Lusebrink (1990) stated that in schizophrenia, individuals often think in images, which are nonverbal and symbolic, rather than in words. She explained that individuals with schizophrenia lack development of ego functioning, whereas individuals suffering from schizophreniform disorder do not. Therefore, she claimed that individuals suffering from schizophrenia are not able to symbolize, and may not be proficient in verbal communication, unless they have schizophreniform disorder, where the pre-morbid history of an individual reveals a healthy ego development. Since the research of Naumburg (1950) and Reitman (1951), there has been limited research in the area of symbolism in the graphic imagery of persons who are mentally ill, with the exception of Wilson (1985) who has provided a few articles for review. This fact supports the notion and need for the advancement of this research topic. The understanding of symbols inherent in artwork created by persons with schizophrenia may lead to a better understanding of the schizophrenic world.
The Research Question
The Research question is, Can the introduction of symbolic art therapy increase the verbal and symbolic output of adult psychiatric patients diagnosed with schizophrenia?
Definition of Terms
The following terms are defined by the American Psychiatric Association (APA), (2000).
Schizophrenia A psychotic disorder characterized by loss of contact with the environment, by noticeable deterioration in the level of functioning in everyday
3 life, and by disintegration of personality expressed as disorder of feeling, thought (as in hallucinations and delusions), and conduct. Schizophreniform Disorder This disorder is classified as identical to schizophrenia with the symptoms lasting for at least a month, but less than six months. This mental disorder is diagnosed when the symptom criteria for schizophrenia are met, but the duration is too short and social and occupational functioning may not be impaired. This diagnosis falls between the qualification for schizophrenia and a brief psychotic disorder. The illness is usually precipitated by an external factor or force. The pre-morbid history of the individual entails a successful ego function development (Lusebrink, 1990).
The following terms are defined by the Merriam-Webster Dictionary (2004). Visual Imagery A vivid or graphic representation or description, including symbols and themes. Theme A subject or topic of discourse or of artistic representation. Symbol An object or image that an individual uses to represent something; a visible sign of something invisible. Wilson (1985) defines a symbol as “a representational object that can be evoked in the absence of an immediate external stimulus” (p.79). Delusion Firmly held erroneous beliefs due to distortions or exaggerations of reasoning and/or misinterpretations of perceptions or experiences. (Delusions of being followed or watched are common, as are beliefs that radio or TV programs, etc., are directing special messages directly to the person.)
4 Hallucinations Distortions or exaggerations of perception in any of the senses, although auditory hallucinations (“hearing voices” within, distinct from one’s own thoughts) are the most common, followed by visual hallucinations.
The following terms are defined by David W. Carroll (1999). Semantics The meanings of sentences and words. Perseveration A perseveration occurs in verbal speech when an earlier segment replaces a later item. Repetition Something that is repeated, especially unnecessary words.
The following terms are defined by the American Psychiatric Association (APA) (2000). Alogia An impoverishment in thinking that is inferred from observing speech and language behavior. There may be brief and concrete replies to questions and restriction in the amount of spontaneous speech (poverty of speech). Sometimes the speech is adequate in amount but conveys little information because it is overconcrete, overabstract, or stereotyped (poverty of content). Aphasia An impairment in the understanding or transmission of ideas by language in any of its forms- reading, writing, or speaking- that is due to injury or disease of the brain centers involved in language. Aphonia An inability to produce speech sounds that require use of the larynx that is not due to a lesion in the central nervous system.
5 Derailment (“loosening of associations”) A pattern of speech in which a person’s ideas slip off track onto another that is completely unrelated or only obliquely related. In moving from one sentence or clause to another, the person shifts the topics idiosyncratically from one frame of reference to another and things may be said in juxtaposition that lack a meaningful relationship. This disturbance occurs between clauses, in contrast to incoherence, in which the disturbance is within the clauses. An occasional change of topic without warning or obvious connections does not constitute derailment. Echolalia The pathological, parrotlike, and apparently senseless repetition (echoing) of a word or phrase just spoken by another person. Flight of Ideas A nearly continuous flow of accelerated speech with abrupt changes from topic to topic that are usually based on understandable association, distracting stimuli, or play on words. When severe, speech may be disorganized and incoherent. Incoherence Speech or thinking that is essentially incomprehensible to others because words or phrases are joined together without a logical or meaningful connection. This disturbance occurs within clauses, in contrast to derailment, in which the disturbance is between clauses. This has sometimes been referred to as “word salad” to convey the degree of linguistic disorganization. Mildly ungrammatical constructions or idiomatic usages of characteristic of particular regional or cultural background, lack of education, or low intelligence should not be considered incoherence. The term is generally not applied when there is evidence that the disturbance is due to an aphasia. Pressured Speech Speech that is increased in amount, accelerated, and difficult or impossible to interpret. Usually it is also loud and emphatic. Frequently the
6 person talks without any social stimulation and may continue to talk even though no one is listening.
The following terms are defined by Goldberg, Aloia, Gourovitch, Missar, Pickar, and Weinberger (1998). Phonological Fluency Test In the phonological fluency test, the subject is requested to name as many words as possible that begin with the letters f, a, and s in consecutive 1-minute time periods. The dependent measure is the number of words retrieved, exclusive of perseverations, repetitions of a word root, proper nouns, or words that began with a letter other than the one specified. Semantic Fluency Test In the semantic fluency test, the subject is requested to name as many animals, fruits, and vegetables as possible in consecutive 1-minute time periods, exclusive of perseverations or out-of-category words.
Brief Overview of the Study
This study attempts to gain insight into the development and/or reacquisition of verbal language production in adult psychiatric patients diagnosed with schizophrenia and schizophreniform disorder. Two psychiatric patients, one diagnosed with schizophrenia and the other diagnosed with schizophreniform disorder, were studied over a four-week period. Tables and charts were created using a collection of language production data for comparison between the two disorders.
Summary
This chapter has been a brief overview to the background of the research study, including the purpose and justification for the research, the stating of the
7 research question, and definition of terms relevant to the understanding of the research study.
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CHAPTER 2
REVIEW OF THE LITERATURE
Introduction
A search of literature was conducted to review the research in two primary areas (1) art therapy with adults diagnosed with schizophrenia and (2) the language production of individuals diagnosed with schizophrenia. The purpose of this review is to provide the researcher with relevant historical information regarding schizophrenia and to provide a basis for the utilization of art therapy with adult psychiatric patients diagnosed with schizophrenic-type disorders. This review gives an overview of the two aforementioned areas with available literature. The researcher had difficulty finding literature available on a similar topic to that of the research study. Therefore, the researcher explored and studied the components of the research question to formulate the hypothesis. For example, the connection between schizophrenia and schizophreniform disorders were studied and then incorporated into language production literature concerning mental illnesses.
Search Techniques The review of literature contains sources including articles from scholarly journals, textbooks, and from Internet databases. The searches were conducted
9 using Florida State University’s Web Luis Browser, including the databases of Psych Info, Psych First, Science Direct, and The Arts in Psychotherapy. Manual searches were conducted to review the literature of art therapy journals and textbooks, including the American Journal of Art Therapy, and Art Therapy. Key words used in the searches were schizophrenia, schizophreniform, art therapy, art therapy and mental illness, art therapy and schizophrenia, schizophrenic art, art and psychosis, artwork and mental illness, psychiatric and art, language production, communication, communication disorders, schizophrenia and communication, symbols, and art therapy and symbolism. There were no parameters for this search due to the lack of similar literature on art therapy and language production. The use of the acquired articles, textbooks, and books provided the information for all of the areas of literature review.
History of Schizophrenia
It could be inferred that mental illnesses, including schizophrenia, have been present throughout the history of time. It appears that psychotic symptoms have been recorded throughout the history of time in various writings including the Bible and in Roman literature (Comer, 1999). Throughout history this disease has plagued the human race, characterized by a permanent deterioration to the person’s vessel. Many of these individuals would never recover from the grips of this horrible malady. According to Bleuler (1950), Emil Kraepelin, a well- respected physician, labeled the mysterious illness “dementia praecox” in 1899, referring to the deterioration of the cognitive processes of the brain, which would leave many permanently disabled. Early physicians called this disease “demence precoce,” “praecox symptom,” “periodic psychosis,” and “primary dementia.” Kraepelin began to distinguish categories of symptomology that included catatonia, paranoia, and hebephrenia. These groups would later become subtypes of this disorder as defined by the American Psychological Association. Yet, Kraepelin noticed that some of the individuals afflicted with this illness did
10 indeed recover from the psychotic break; perhaps those few cases would include individuals afflicted with schizophreniform disorder. Later in 1911, Bleuler renamed this disease “schizophrenia,” which literally translates to the splitting of associative threads, to characterize a persistent, often chronic and usually serious mental disorder that affects a person’s behavior, thinking, and emotion (Bleuler, 1950). Bleuler felt the name of this disease should be changed for many reasons. He stated that the term dementia was inappropriate as …“I call dementia praecox “schizophrenia” because (as I hope to demonstrate) the splitting of the different psychic functions is one of its most important characteristics” (p. 8). Diagnostic Criteria According to the American Psychiatric Association (APA) (2000), the essential features required for a diagnosis of schizophrenia include positive and negative symptoms “that have been present for a significant portion of time during a 1-month period (or for a shorter time if successfully treated) with some signs of the disorder persisting for at least 6 months” (p. 298). Two or more symptoms must be present, including delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, or negative symptoms. Such negative symptoms include affective flattening, alogia, and/or alvolition. For a complete listing of the different subtypes of schizophrenia and related disorders, which include paranoid type, catatonic type, disorganized type, undifferentiated type, residual type, schizoaffective disorder, and schizophreniform disorder, see Appendix B.
The History of Schizophreniform Disorder
According to the Diagnostic and Statistical Manual of Mental Disorder (Edition IV-Text Revised), the characteristic symptoms of schizophreniform disorder are the same criteria for schizophrenia, but the duration is markedly shorter, and social and occupational functioning may not be impaired. An episode of the disorder (including prodromal, active, and residual phases) lasts at
11 least one month but less than six months. (When the diagnosis must be made without waiting for recovery, it should be qualified as "Provisional.")
Visual Imagery in Schizophrenia and Schizophreniform
Lusebrink (1990), in her book Imagery and Visual Expression and Therapy, explored the differences found in visual imagery between schizophrenia and schizophreniform disorders, as well as the implications therein. Schizophrenic disorders cause a slow destruction of normal thought processes, behavior and emotion. She described the effects of the illness on perception and cognition. For example, she stated that in schizophrenia, individuals may experience an array of feelings including hazy perception, being flooded with mental images, thinking in images rather than in words (nonverbal and symbolic), and feeling confused between figurative and literal meaning. Lusebrink stated, “In schizophreniform disorder, the illness has a different pre-morbid history and is assumed to have a different etiology from schizophrenic disorder” (p.192). She further explained that individuals diagnosed with schizophreniform disorder have a previous history of adequacy in the areas of social and economic realms, as well as appropriate sexual adjustment. Schizophreniform disorder is often precipitated by an external factor or force. This supports a possible avenue of research (studying the effects of art making of clients with a developmental illness such as schizophrenia, paired with a client diagnosed with a mental illness acquired through trauma or like event, such as schizophreniform) by confirming the notion that the symbolism would be accessed faster or more readily with a client suffering from schizophreniform disorder; before the onset of schizophreniform the individual had developed healthy ego functioning, relating to the ability and possibility to symbolize in art making. Lusebrink qualified the value of art therapy when she stated, “The inner upheaval and the experience of self and environment in both schizophreniform disorder and schizophrenia are such that the individuals resort to nonverbal and
12 earlier forms of representation and communication” (p.197). Lusebrink based this idea on her practice as well as on the work of others. For example, Volmat (1956) found that the visual expression of people suffering from schizophrenic disorders serve a purpose of communicating their experiences to others through the art making process, subsequently discovering meaning in the art product. Even though visual expression may be a spontaneous activity for people with schizophrenia, Lusebrink found that a therapeutic plan for art making with such clients should emphasize structure, reality orientation, and socialization. To assist art therapists with developments of a treatment plan, Lusebrink developed a model which she called the Expressive Therapies Continuum (ETC). On the ETC, the therapist should begin with the kinesthetic/sensory level, progressing to the cognitive level in which the client may understand symbols on a nonverbal level. When possible, discussion of symbols may follow. Lusebrink qualified that “the perception and verbalization facilitates the separation of the different levels of representation, combining them into a meaningful sequence” (p. 214). Ideas for eliciting verbal communication after art making were recommended by Lusebrink, including utilization of the continuity of therapy sessions through periodic review of artwork. Lusebrink stated, “The significance [of visual expressions] may not be shared verbally with the therapist in the acute phase [of schizophrenia], but the patient distinctly remembers and shares it with the therapist upon review of the work later in the reconstitutive process” (p.199). A review of artwork may create a sense of safety in symbolic objects and thereby increase the ability to express meaning verbally. The technique of reflective distancing also contributes to this occurrence. Lusebrink asserted that the progress in visual expression made by clients suffering from schizophrenic disorders evolves from nonrepresentational and cryptic symbolism towards recognizable objects, and lastly towards realism. Visual expressions become more organized and familiar as art therapy continues.
13 Schizophrenic Disorders and Therapy
Lysaker and Lysaker (2001) stated that the experience of a psychosis like schizophrenia is marked with the breakdown of a dialogue imperative for successful communication with the outside world, corresponding to a disturbance in associative processes in cognitive functioning. From a psychoanalytic perspective, schizophrenic behaviors or characteristics may be associated with anger or aggression that overwhelms the psyche, resulting in an inability to properly communicate. Frith (1997) asserted that thought disorders, such as schizophrenia, “reflect a lack of ideas, difficulties with planning a discourse and a tendency to perseverate on certain themes” (p. 10). He continued to argue that individuals diagnosed with schizophrenia possess an overall absence or poverty in the rate of speech, content, and accompanying gestures or expressions. Frith believed that this difficulty arises from deficits in the acknowledgment of discourse between two or more people in the individual’s mind, as well as an inability to understand that there is indeed a conversation taking place. Amos (1982) hypothesized that the chance or likelihood of success by means of therapeutic communication with an individual diagnosed with schizophrenia becomes progressively more dismal. Therefore, Hacking and Foreman (2001) made a bold statement alluding to the person’s (diagnosed with schizophrenia) wants and needs for communication when they asserted that “disturbed people, particularly schizophrenics, often produce artwork that is communicative in a way that their language is not” (p. 35).
Language Dysfunctions in Schizophrenia
According to Gourovitch, Goldberg, and Weinberger (1996), impairments in language production are an associated feature identified in individuals suffering from schizophrenic disorders. Specifically, such impairments are noted in the areas of spontaneous speech, object naming, comprehension, phonological fluency, and judgment of semantically nonsensical sentences. Most
14 notable are the dysfunctions in semantic processing. Schizophrenic speech disturbances demonstrate an inability to organize linguistic elements into meaningful structures. Goldberg, Aloia, Gourovitch, Missar Pickar, and Weinberger (1998) stated that the thought disorder inherent in schizophrenic disorders results in language production difficulties. Goldberg, et al. (1998) cited studies that suggested individuals suffering from schizophrenia suffer multilevel language disturbances, including the misuse of semantics and phonological features of words. Results of the study concluded that “thought disorder in schizophrenia is associated with and may result from semantic processing abnormalities.” In addition, it is perceived that individuals with thought disorders “may have difficulty accessing semantic items because of disorganization of the semantic systems and, to a more limited degree, may also lack a semantic or conceptual knowledge base.” Both aforementioned studies implemented verbal fluency tasks including phonological and semantic measures to test the semantic processing and word production capabilities of participants. Such tasks require “strategic retrieval and access to phonological/orthographic or semantic lexical information.” Results find that a breakdown in semantic knowledge affected the search and retrieval mechanisms needed to score high on the semantic fluency test (Gourovitch, et al., 1996).
Nonverbal Communication
Cohen (1981) cited Cesare Lombroso and his theory, which entailed a notion that “a perceived sense and meaning in the pictures drawn by psychotic individuals and concluded that they were thus expressing ideas which they were incapable of expressing verbally” (p.15). As noted above, individuals diagnosed with schizophrenia or other related thought disturbances have great difficulty engaging in suitable and successful conversations. Lysaker and Lysaker (2001) stated that, “The experience of psychosis can be conceptualized as a breakdown of dialogue within the self and between self and others” (p. 27). This dialogical
15 characteristic is often missing in the understanding of the world as viewed when in a schizophrenic state of mind. Amos (1982) inferred that, “It may be the schizophrenic’s hope that there will be another person who will understand, in nonverbal terms, the meaning of such communication” (p. 132). The interaction of the visual and verbal pathways of the brain is delineated by the separation of the two hemispheres. The picture, which is visual, is sent through the right cerebral hemisphere and the verbal is sent through the left cerebral hemisphere. To maximize the impact of art therapy as a relationship between the visual and verbal pathways of the brain, the visual and verbal should run contemporaneously. Birtchnell (2002) claimed that, “The therapy is maintained within a visual-verbal enmeshment: words evoking new pictures, and pictures evoking new words” (p. 6).
Art Therapy
The American Art Therapy Association (2004) cited the definition of art therapy as follows: “Art therapy is based on the belief that the creative process involved in the making of art is healing and life-enhancing. Through creating art and talking about art and the process of art making with an art therapist, one can increase awareness of self, cope with symptoms, stress, and traumatic experiences, enhance cognitive abilities, and enjoy the life-affirming pleasures of artistic creativity.” According to Cohen (1981), “Art therapy may be viewed as a process which facilitates the patient’s communication of the unconscious determinants of his illness through the use of various art media.” The art therapist, in conducting art therapy with such individuals, may observe the happenings of “the symbolic projectionism in the work” (p.16). Specifically, the art therapist may witness the development of major symbols and themes present in the artwork of a client over a period of time. Potocky (1993) noted that art therapy can prove to be one of two things. It can be a leisure activity utilized to fill time, or it can be used to “yield insights into
16 clients’ intrapsychic processes” (p. 78). Birtchnell (2002) believes that “what is special about art therapy is not so much the process as the unique combination of two separate mental processes that are a consequence of the creation of visual representations of patients’ preoccupations and their talking about them” (p. 8). Art therapy allows a person who may be resistant to verbal therapy to engage in a less threatening means of communication, through art. The art provides an outlet for the person to express himself, which afterwards may lead to a verbal discussion on the topic.
Art Therapy and Mental Illness
The approximate date of the birth of art therapy practices in the mental health field is unknown. It seems that individuals such as psychiatrists, psychologists, and some staff members working in psychiatric facilities began to notice the art of persons with mental illnesses. Wood (2002) surmised that art therapy in psychiatric facilities first emerged in Europe, where professionals merely wished to understand the mental illness in hopes of helping the patient in some way. He reported that this interest was slow-moving, as “Gradually, it became apparent that the artwork made by people in the midst of psychosis often resonated with a more general need to understand those matters which lie below the surface” (p.152). Marinow (1971) found from her personal experience with the psychiatric population that “Not only are physical delusions sometimes represented in drawing and painting, but also auditory and tactile hallucinations are as likely to be portrayed as visual ones” (p. 45). Kramer (1982) cited Nolan Lewis, M.D. and his ideas on the connections between art and psychosis. Lewis was a practicing clinical psychiatrist at Saint Elizabeth’s Hospital in Washington, D.C. in the early 20th Century. He began to notice the relationship between art and mental illness, hypothesizing that “art expressed unconscious motivation, defense mechanisms, narcissistic tendencies, and states of change in transference” (p. 75). Prentiss Taylor was an art therapist at Saint Elizabeth’s following Lewis’ term. He felt that
17 this form of therapy led to “encouraging graphic expression by means of which patients might elect to complement their verbal treatment” (p. 78).
Art Therapy and Symbolism
Wilson (2001) stated that symbolism and the ability to create symbols are formed concurrently with the development of ego functioning. Symbols are essential for the process of development; “symbolism is a crucial type of mental representation, since it provides the building blocks for other, more complex mental representations: images, fantasies, thoughts, concepts, dreams, hallucinations, symptoms, and language” (p. 41). Wilson then approached the concept of symbolism in relation to pathology including retarded ego development, schizophrenia, and organic brain disease. Each of these ailments characterizes the patients with dysfunctions in symbol formation and a disturbance of the reality function of the ego. In each category and case study included, Wilson concluded that patients with “impaired symbolic function can be helped, by the making of visual images, to develop the ability to symbolize” (p. 47). Specifically, it is the visual imagery inherent in the creation of art, which promotes healthy ego functioning. She later discussed mental representation of symbols and the psychic energy released through this process, which together bring the unconscious to conscious awareness. She stated that the process of using visual imagery to create symbols can facilitate consciousness. Wilson maintained that “When using language is too difficult - or too frightening - practice in symbolizing, by making visual images, can further development” (p. 47). This statement is important in this research as the hypothesis is that communicative language is more difficult in production and expression than via art making. Additionally, in her discussion of schizophrenia, Wilson pointed out that through art therapy, clients display repeated key symbols “with a gradual recognition of their meaning, and a consequent ability to differentiate reality from fantasy” (p. 44). She later noted that some individuals
18 diagnosed with schizophrenia may be willing to speak and verbalize feelings, yet they may lack the mental capacity to organize thoughts and perceptions. Engaging in art with these individuals may elicit their ability to communicate without verbalization. Wilson also asserts that “perhaps art is effective in such a case because the external symbolic representation allows distance to be created between the individual and the conflict” (p. 49). Wilson later attributed the art making to a defense mechanism. She later added to this idea by remarking that “making artwork frees patients who are blocked in verbal expression” (p. 49). Verbalizing feelings and emotions through language requires conscious levels of awareness; art making offers people a way of utilizing the preconscious or subconscious ideas in their art without those ideas being in their conscious awareness.
The Use of Symbols
Cohen (1981) believed that once a therapist is introduced into the schizophrenic state of mind, she will be able to encourage and possibly motivate the client into a verbal communication of his images. However, with only the graphic expression of a client, symbolism may not be apparent to the therapist; the symbol may be known only to the client. He stated, “In most instances, the patient-artist is unaware of the symbols he employs which we [art therapists] believe are derived from the unconscious. Typical symbols seen in persons diagnosed with schizophrenia are related to expressions of aggression, regression, fear, anxiety, and sexual conflict” (Cohen, 1981). Wilson (1985) stated that “a symbol is a representational object that can be evoked in the absence of an immediate external stimuli” (p. 79). Types of symbols include expressive, suggestive, and substitutive symbols (Reitman, 1951). The symbol is then transformed into a concrete meaning and experienced as the over-arching meaning. Reitman (1951) believed that the decision-making process involved in what is created by a person is often dependent upon the internal conflicts of that
19 person, and that the motivation behind a creation may be of high significance and importance to the artist alone. He explored the link between the symbol and emotion of persons with mental illnesses, pairing them together, by which the object is reduced to the symbol to escape the intolerable experience of intense and unpleasant emotion. Reitman continued this idea by his statement that such a release of tension via creativity is the process of sublimation, the symbolic expression of subconscious conflicts. Therefore, if such symbols are born in the unconscious, the meaning is characterized as latent content which the therapist would need the person’s verbalization of the symbol to correctly link one with the other. Reitman (1951) acknowledged that “the hypertrophy or enlargement of symbols is a usual phenomenon in schizophrenic paintings, and psychiatrists have explained it in terms of schizophrenic thought disturbances” (p. 36). Wilson (1985) contended that due to the nature of the mental illness, and the prospect of the individual experiencing a loss of or difficulty with reality functioning, the symbolic processes malfunction. Consequently, individuals with this mental illness lose the ability to distinguish between the object and its representational symbol.
Limitations
Marinow (1971) addressed the inherent difficulty in the interpretation of symbols found in artwork created by persons suffering from mental illness; symbols found in such artwork may be unintentional, complex, or difficult to decipher. Interpretations of any symbol are open to the discretion of the individual. This belief is widely held in the therapeutic community and merits discussion. Therefore, before the participant’s artwork was coded for the use of symbols, precautions were taken to ensure that what was interpreted was indeed a symbol as related to the participant’s verbal description. Limitations of the study include the problem of confounding variables. It is likely that extraneous variables may be the origin of an increase or decrease in
20 language production as measured by verbal fluency testing. In addition, non- specific factors such as researcher warmth and attention may influence language production. There is a strong likelihood that the participants of this research study were engaged in additional treatment to the art therapy intervention. For example, participants may have been involved in medical treatment, psychological therapy, and social therapy. Other limitations of the study entail experimenter expectancy, which is the tendency of the investigator to see what is expected, thereby misinterpreting responses. Also, the possibility of experimenter reactivity was inherent, which is a tendency of the investigator to influence the behavior of participants, intentionally or unintentionally. The researcher will attempt to control these extraneous variables through constant self-reflection and supervision.
Summary
According to researchers, psychiatrists, and theorists, the mental illness of schizophrenia causes debilitating cognitive deficits including thought disturbances. Such thought disturbances may result in language deficits and or difficulties in language production. For example, an individual diagnosed with schizophrenia may experience difficulties including perseverations, repetitions, alogia, aphasia, aphonia, derailment (loosening of associations), echolalia, incoherence (word salad), and pressured speech (see definition of terms). This makes communicating with others extremely challenging and exhausting. Therefore, the researcher hypothesizes that the introduction of art therapy into the treatment plan of an individual diagnosed with a schizophrenic-type disorder may elicit improved language production as evidenced by measures of verbal fluency. As Wilson (1981) described, making symbols through artwork may lay a foundation for the higher mental processes to develop, such as language.
21
Language
The Ability to Symbolize
Ego Development
Figure 1 Hierarchy of Mental Processes
Phonological Fluency
Semantic Spontaneous Judgment Speech Language
Object Comprehension Naming
Figure 2 Frequent Speech Errors Derived from Gourovitch, Goldberg, and Weinberger (1996)
22
CHAPTER 3
METHODOLOGY
Introduction
The general purpose of this study is to assess the language production data compiled through a series of measures in relation to an art therapy approach to treatment for individuals with mental illnesses. The significance of this study is to determine art therapy’s role in language production via symbol formation. The research question is, Can the introduction of symbolic art therapy increase the verbal and symbolic output of adult psychiatric patients diagnosed with schizophrenia? To answer this question, the following objectives of the study have been identified: 1. To gain a better understanding of the artwork created by adults diagnosed with schizophrenia. 2. To better understand the symbols made within the artwork created by adults diagnosed with schizophrenia. 3. To research the possibility of symbolic art making increasing verbal language production as measured by various tests. 4. To assess the similarities and differences between individuals diagnosed with schizophrenia and schizophreniform disorder. To describe and organize the process of this research study, the following procedures have been identified: 1. Collect language production data through a series of tests.
23 2. Collect artwork reflecting the symbolic processes of the participants. 3. Code the artwork for themes. 4. Compare the language production data from both participants.
Description of Research Design
The research design used a case study format. The researcher studied two individuals involved in art therapy to collect information that will provide data on language production in respect to art therapy. The researcher utilized an A-B single-subject design to collect data on language production by testing fluency on phonological and semantic levels. One question (identical throughout the research project) was asked of each participant before each individual art therapy session. The verbal response was scored to collect speech errors in language production data. This type of research has a high level of constraint due to the nature of the investigation, which is a case study format.
Description of Sample
The sample population consisted of 2 females suffering from schizophrenic-type disorders. Both participants were volunteer psychiatric patients. The research was conducted at a private psychiatric clinic where the diagnosis of schizophrenia and schizophreniform was likely. The subjects of this research were recruited based upon convenience and purpose, specifically, adult psychiatric patients diagnosed with schizophrenia. The researcher was provided with a list of potential participants for the study by the facility where the research was conducted. Two subjects diagnosed as having schizophrenia-type disorders participated in this study. Each of the individual’s etiologies differed. One participant was diagnosed with a developmental or chronic schizophrenia while the other is diagnosed with a trauma, or trigger-induced schizophrenia, termed schizophreniform disorder.
24 There is limited generalizability of this study due to its specific nature and limited participants. Participants were required to sign a consent form informing them of the possible harm in participating in the study, including stress and discomfort which could emanate when disclosing or expressing information and images that could be painful. Before any person was asked to sign the consent form, the researcher consulted with staff therapists to determine mental competency. Participants were at any time able to discontinue with the research study without penalty. Additionally, the confidentiality of each participant was safeguarded at all times as stated in the consent form.
Description of Instruments
The instruments used in this research study were a pre-determined set of art therapy directives that focus on symbolization. The four directives included a scribble drawing, a personal symbol drawing, a personal symbol sculpture, and a mandala painting. Before each art therapy session, the participant was asked one open-ended question. Descriptive data of the nature of the speech errors produced during each utterance was recorded. In addition, verbal fluency tests of phonological and semantic understanding were administered to establish levels of language production. A tape recorder was utilized to maintain accuracy of language productions and utterances. The tapes were coded by numbers and then scored to reduce researcher bias. The tests of verbal fluency originate from research on the cognitive impairments in individuals diagnosed with thought disorders such as schizophrenia. The tests of verbal fluency were designed to compare the phonological and semantic functioning levels of individuals suffering from schizophrenia with a control group. The tests have been utilized multiple times by the researchers (Gourovitch, Goldberg, & Weinberger, 1996; Goldberg, Aloia, Gourovitch, Missar, Pikar, & Weinberger, 1998). In both published studies, the group of individuals suffering from schizophrenia scored lower than the control group on measures of phonological and semantic fluency. The authors have
25 indicated that the cognitive deficits inherent in schizophrenia result in the low scores on the verbal fluency tests.
Procedure
Participants were tested on phonological and semantic fluency upon the start of the research. In addition to the baseline reading of phonological and semantic fluency, participants were also tested at the conclusion of the research project. Throughout each session, the researcher engaged in verbal conversation with the participants. Birtchnell (2002) stated that to maximize the efficacy of art therapy, the visual and verbal pathways should be run contemporaneously. Individual art therapy services were given to participants one time per week for four weeks. The art therapy services rendered focused upon symbolization. By utilizing a symbolic approach to art therapy directives, the participants were exposed to processes of symbol formation. In the first art therapy session of the research project, the participant was instructed to create a scribble drawing. In this directive, the participant was instructed to scribble on a blank piece of paper with any color marker she chose. The participant was directed to close her eyes while making the scribble if she felt comfortable doing so; by closing one’s eyes while making a scribble, the individual will be less likely to judge the scribble as poor and will not know the outcome until she opens her eyes once again. In doing so, the participant could not see what the scribble looked like until she finished. After the scribble was completed, the participant was instructed to place the paper on the ground and walk around it, looking for an image to appear; the participant projects onto the scribble what is in her unconscious. The researcher did not aid the participant in finding an image within the scribble drawing, but encouraged her to try her best. This approach utilizes the participant’s unconscious by allowing an image within the scribble to come to the surface, or preconscious of the individual. After the participant had found an image, she was instructed to utilize various media available, including pencils, colored pencils, markers, and pastels, to complete the image found in the
26 scribble. On the ETC this directive is on a kinesthetic level as the participant is required to scribble on the page. However, the directive also incorporates the perceptual level when the participant is asked to find an image in the scribble. After the scribble drawing image was completed to the satisfaction of the participant, the researcher asked the participant questions about the scribble and the image found within. The second art therapy session focused on personal symbols. On the ETC, this directive is on the cognitive and symbolic levels. The participants were required to process information and create a personal symbol. To make sure that the participant understood the meaning of a symbol, the researcher engaged in a discussion with the participant about what a symbol is. The researcher then asked the participant to brainstorm ideas for her personal symbol. A sheet of paper and pen was available for the individual to use if she so desired. After the participant came up with a personal symbol that she felt comfortable with, the participant was instructed to draw that symbol. Media available to the participant included markers, colored pencils, and pastels. The participant was allowed to start again if she did not like the image that she first produced. After the image was complete, the researcher asked the participant questions about the personal symbol in relationship to the participant. The third art therapy session in the sequence of the research project entailed the participant to transform the two-dimensional image from the week before into a three-dimensional image. On the ETC, this directive is on the kinesthetic and sensory levels. For example, the participants were instructed to manipulate three-dimensional materials to create the sculpture. However, the participants were also asked to utilize the symbolic level to translate the two- dimensional symbol into a three-dimensional one. The previous week’s artwork was available for the participant to view. Media available to the participant included clay, plasticine, play dough, pipe cleaners, markers, colored pencils, glue, and tape. After the three-dimensional images were complete, the researcher asked the participant questions about the artwork.
27 The fourth art therapy session in the research project was a mandala painting. According to Jung (1964) a mandala is a universal symbol, which brings about an inner peace to the individual creating it and “consolidates the inner being” (p.230). In the painting, the participant was asked to fill it however the participant chose, but to reflect on the past four weeks, and to include her personal symbol if it was appropriate. The researcher chose this intervention to calm and ground the participant in the last session. The researcher felt that the mandala would allow the participant to comfortably express any emotions and feelings while reflecting on the past four sessions. On the ETC this directive was a cognitive exercise. The participants were required to process information from the previous sessions and utilize that information to create a painting. Additionally, the researcher engaged in verbal conversation pertaining to the client’s artwork during the art-making process. The researcher aided the client by giving assistance with materials (collection, clean up) and in any other task if indicated by the participant. After the artwork was completed during a session, the client was allowed to verbalize any concerns, emotions, or feelings that may have been evoked during its production, as processing is an important part of the closure needed by each client after engaging in a therapy session. Periodic review of the artwork as suggested by Lusebrink (1990), was utilized and aided in verbal communication between researcher and participant at the end of each session.
Internal and External Validity
Internal validity is limited due to the nature of a psychiatric facility. Variables such as interaction with other clients, staff, and family can impact the research project on a day-to-day basis. Additionally, factors that may affect validity include the participant’s characteristics, the time of day, and situational distractions. These variables present a threat to the validity of the research and should be noted. The researcher attempted to minimize these threats by scheduling the art therapy sessions at the same time of day and the same day of
28 each week. However, due to transportation difficulties, sessions were not always conducted on the same day of the week. In addition, the same rooms were utilized for each portion of the session. The external validity of the study, or the degree to which generalizations can be made to the larger population, is extremely limited. This is due to the small sample size and the location of the research, which is in the southeastern United States.
Statistical Techniques
Data analysis for this study was conducted on the language production data as well as the artwork created by the participants. Analysis of the language production data included the use of charts and graphs to compare the participants’ pre-tests and post-tests as well as comparing the participants to one another. Analysis of the artwork was conducted in a qualitative manner. The artwork was coded for themes and symbols.
Ethical Considerations
Ethics that the researcher abided by are governed by the University’s Human Subjects Committee and the Institutional Review Board of the mental health clinic; both bodies oversee research over human subjects. An approved consent form informed participants of the risks involved in participating in the study. Confidentiality was maintained at all times. The participants were debriefed after the study ended, and were able to view the results upon request. In addition, protecting the rights of all persons was of foremost of importance. Participants had the right to discontinue participation at any time. Alternative therapies were available if needed.
29 Summary
The following chapter discussed the methodology designed for the research project, including objectives and procedures of the study, a description of the research design and sample participants, a description of instrumentation and art therapy directives utilized, internal and external validity, statistical techniques, and ethical considerations. The following chapter will detail the case presentation of the two participants of the study.
30
CHAPTER 4
CASE PRESENTATION
Introduction
The following is a case presentation of the participants of the study entitled: Schizophrenic Communication: Art Therapy and Language Production. Two volunteer psychiatric patients were asked to take part in the research project. By volunteering to be research participants, the individuals aided the researcher in ascertaining language production data as it relates to the art therapy services rendered. Both participants were identified with a DSM-IV-TR diagnosis of a schizophrenic-type disorder. Participants of the research study were informed about the study, the risks, and the expectations of the participants prior to its beginning. The participants were informed that at any time during the research project participation could be revoked without penalty or prejudice. Before the first meeting, the researcher informed the prospective participant of the research study and its risks and benefits. Before an individual could participate in the study, an approved informed consent form was signed. Participants were notified that the artwork created during each session would be digitally photographed and returned to the participant after completion of the research study. Participants were also informed that confidentiality would be maintained; artwork was given a numeric code and labeled, excluding the participant’s name or any identifying information. The participants were notified that each session would be tape-recorded to rule out human error in data
31 collection. After the consent form was signed and questions were answered to the satisfaction of the participant, the researcher collected language production data via verbal fluency tests designed by Gourovitch, Goldberg, and Weinberger (1996). The researcher tape-recorded the tests to maintain accuracy and to reduce experimenter bias or error. After the pre-tests for verbal fluency were conducted, the researcher asked the participant the standardized inquiry to be asked at the beginning of each session: “Tell me about your day.” Session Setting The researcher met with each participant once per week for four weeks. Sessions were conducted in two small, adjacent offices at a private psychiatric clinic in the southeastern United States. One room was used to collect language production data and the other room, accommodated with adequate table space, was used for the art therapy sessions. The atmosphere of both rooms was quiet, private, and comfortable.
Participant 1
Belle Participant 1 (Belle, pseudonym) is a 52-year-old white female diagnosed with schizophreniform disorder, without good prognostic features. The following information was obtained through a treatment summary from her current therapist, with her permission. Background Belle was raised in the southern United States. Her educational background consists of graduation from high school. Soon after her graduation, she married. The first marriage failed due to domestic violence and physical abuse, which was reported by the participant. Belle is currently married and has two children. Belle’s daughter is an inpatient at a southern psychiatric hospital diagnosed with schizophrenia. Her son was recently murdered in a neighborhood stabbing incident. She has a history of substance abuse and reports difficulty
32 sleeping through the night. Belle is unemployed, receives mental health disability, and is undergoing bankruptcy settlement. Presenting Problems Belle presented to therapy on 12/08/2003 with symptoms of trauma stemming from the murder of her son. She reported flashbacks, difficulty sleeping and eating, and mood instability. Sometime after the trauma, Belle began experiencing psychotic symptoms including visual delusions and auditory hallucinations. She currently experiences symptoms of depression, anxiety, delusions, and hallucinations. Psychosocial Stressors At the time of the study, Belle reported serious psychosocial stressors with her family. Most notable is her relationship with her husband. During sessions, she would comment on the troubles she was experiencing of making her marriage last. Also, her relationship with her daughter causes Belle immense stress. Her daughter, who is an inpatient at a residential treatment facility, calls her mother often and asks her to come visit. Due to her financial problems, Belle is not able to travel to visit her daughter. Belle has also commented that she is constantly worried about her daughter, who has displayed aggressive and violent behavior. Financially, Belle is undergoing bankruptcy settlement. This causes a strain in her familial relationships, as it is constantly a topic of conversation. Due to Belle’s unemployment, she frequently assists her friends in chores and yard work for compensation. This income, however, does not meet her financial needs to pay off her debts. Medications Belle is currently taking an atypical antipsychotic for her symptoms, as well as medication to control her anxiety. Goals and Initial Treatment Plan As noted in the treatment summary supplied by the research facility, Belle’s treatment goals include increasing mood stabilization, decreasing symptoms of depression and anxiety, increasing daily coping skills to address
33 loss and grief issues, increasing self-esteem and self-concept, education concerning her diagnosis, and decreasing the frequency of substance abuse.
Table 1 DSM-IV-TR Diagnostic Information AXIS I 295.40 SCHIZOPHRENIFORM DISORDER AXIS II 799.9 DEFERRED AXIS III TYHROID PROBLEMS AXIS IV PROBLEMS WITH INTERACTION WITH FAMILY MEMBERS AND SPOUSE AXIS V 42
Session 1 The initial session began by informing the participant about her rights as a research participant, the potential harm involved as well as the potential benefit, and the signing of the approved informed consent document. Session 1 included the verbal fluency testing, the qualitative measure “Tell me about your day,” the art therapy intervention, and processing of the finished product. Quantitative Measures After the consent form was signed, the researcher began with the first measure of language production: the tests of verbal fluency, which included phonological and semantic fluency testing. The researcher gave clear directions to Belle about the test, and then the researcher asked if she was ready to begin. Belle appeared anxious and unsure of her ability to perform well on the test. In an attempt to calm her, the researcher asked that she do the best she could do. For a complete transcript of Measure 1 please see Appendix B. After the verbal fluency tests were completed, the participant appeared relieved. Qualitative Measures Next, the researcher informed the participant that she would be asked one question at the beginning of every art therapy session. The researcher then posed the inquiry to Belle: “Tell me about your day.” She responded with a
34 lengthy monologue about her day, which included feelings of her insecurity and uncertainty of decision-making in the near future. The researcher then escorted the participant to an adjacent room that would be used for the art therapy sessions. For a complete transcript of this measure, please see Appendix B. Art Therapy Directive The researcher began the art therapy session by asking Belle if she liked art. She responded that she liked art but was “not good at it.” The researcher then asked Belle if she had ever done a scribble drawing. She laughed and stated that she must have done some when she was a child. The researcher then informed the participant of the aim of the session: to create a scribble drawing. The researcher asked Belle to close her eyes, if she felt comfortable doing so, so that she would not see her scribble until it was complete. She responded by closing her eyes and began scribbling on the paper provided with a blue marker. The researcher stopped Belle after a large portion of the page was covered with a scribble. Next, Belle was instructed to place the piece of paper on the ground and to walk around it, looking for an image to pop out of the scribble. The researcher assisted the participant by turning the picture in different directions so that she might see the picture from different perspectives. The researcher asked Belle if she saw anything. Belle looked up and responded yes, that she saw a figure. The researcher then asked the participant to take the paper back up to the desk and to embellish the image she saw within the scribble. The participant was given a variety of two-dimensional materials to use including markers, pencils, colored pencils, and pens. Belle quickly began to enclose the image with a red marker, outlining a female form. Next, Belle asked if she could add tears to the interior of the figure and the researcher responded that she could. She added tears with a black marker, stating that the tears were rendered black because they hurt. A discussion ensued about the figure and its relationship to the participant. Themes Themes that appeared during the first art therapy intervention include a lack of direction in life, a need for escape, the feelings of guilt, and holding her
35 feelings inside as opposed to sharing them with others. These themes were derived from Belle’s verbal description of the artwork as well as the researcher’s interpretation of the artwork. Conclusion The first session with Belle went well. The task, to create a scribble drawing was accomplished and Belle gained some insight into her current situation, including her underlying depression and anxiety. Belle stated that the tears that she added represented her sadness and that there was no direction in her life.
Session 2 Session 2 included the qualitative measure “Tell me about your day,” viewing of the artwork from the previous week, the art therapy intervention, and processing of the finished product. Qualitative Measures Session 2 began with the inquiry to Belle’s day. She appeared to be more comfortable talking to the researcher than the previous week. She inferred about her insecurity and uncertainty in her relationships and her direction in life. After she was finished, the researcher led her into the art therapy room. For a complete transcript of this measure, please see Appendix B. Art Therapy Directive The researcher began the session by asking Belle if she knew what a symbol was. She stated that she thought she did. A discussion ensued between the researcher and the participant about symbols, including symbols that she might see or use everyday. Next, the researcher asked her to think about what a personal symbol might be. She stated, “It must be a symbol to represent yourself.” The researcher stated that she was correct. The researcher then asked Belle to begin brainstorming what her personal symbol might be. To help the participant, the researcher suggested she think of things that she liked or associated herself with. Within a few minutes, Belle began to draw an image. The image was a wavy, red line with red arrows coming out of it in various places.
36 Belle stated that the red line was she, and that she felt the line was fun as it was not straight. She expressed to the researcher that she felt a straight line was boring in comparison to a wavy line. When questioned about the arrows, Belle stated that these represented the different choices she could make in life, specifying that some choices were bad and others good. A discussion resulted about her feelings about her personal symbol. Themes Apparent themes in the art therapy session included a lack of direction in life, mistakes made in the past, and mistakes waiting to be made in the future. These themes were derived from the verbal accounts of the participant as well as the researcher’s insight into the artwork produced. Conclusion Session 2 was successful in that Belle completed the task at hand, to create a personal symbol. Although the symbol was completed rather quickly, it appeared that Belle was pleased with the finished product and felt that it represented her accurately.
Session 3 Session 3 included the qualitative measure “Tell me about your day,” viewing of the artwork made the previous week, the art therapy intervention, and processing of the finished product. Qualitative Measures Session 3 began with the researcher asking the participant “Tell me about your day.” Belle responded with ease to the question, but did not talk as much as she had in the past. For a complete transcript of this measure, please see Appendix B. Art Therapy Directive The art therapy directive for session 3 was transforming the personal symbol made in Session 2 into a three-dimensional object. The researcher began by informing the participant of the directive. Next, the researcher asked Belle what materials she would like to use. Media available included clay, plasticine,
37 pipe cleaners, tape, glue, markers, colored pencils, and pens. The participant remained quiet and did not answer the researcher for a few minutes, in which she stated that she was thinking. She began collecting materials from the desk, stating that she was not satisfied with the materials available. The researcher asked what else she would like to use and she stated paint. Belle began the art directive by taking two red pipe cleaners and placing them on a sheet of paper. Next, she tried to glue the pipe cleaners down but was unsuccessful. The researcher suggested tape and helped Belle apply the tape as requested. Next, she took glue and began to make the arrows from her personal symbol, later coving them with red paint. She stated that she wanted the arrows to stand out from the page. After Belle stated that she was finished with her symbol, processing of the artwork began. Themes Themes apparent in the art therapy session included a feeling of chaos, uncertainty for the future, and a lack of direction in life. These themes were derived from the verbal accounts of the participant during and after the completion of the directive. Conclusion The third session was successful in that the participant completed the art directive of making her symbol three-dimensional. Belle demonstrated adequate problem-solving skills when the glue would not adhere the pipe cleaners to the paper. She did not display frustration or dislike during the art making process or after its completion.
Session 4 Session 4 included the qualitative measure “Tell me about your day,” viewing the artwork from the previous week, the art therapy intervention, processing of the finished art product, and verbal fluency testing. Qualitative Measures The researcher began the session by asking the participant “Tell me about your day.” Belle responded with extreme difficulty and appeared to be
38 uncomfortable. Her response to the question alluded to her uncertainty and insecurity of her present situation. For a complete transcript of this measure, please see Appendix B. Art Therapy Directive The art therapy directive for the fourth and final session was a mandala painting. In the painting, the participant was asked to fill it however she chose, but to reflect on the past four weeks, and to include her personal symbol if it was appropriate. The researcher chose this intervention to calm and ground the participant in the last session. The researcher felt that the mandala would allow the participant to comfortably express any emotions and feelings while reflecting on the past four sessions. As stated earlier, mandalas are shapes that ground a person, calm the individual, and may provide peace. As the mandala is a circular shape, there is no beginning and end. Therefore, whatever is put inside the mandala can not escape. The mandala is, therefore, a safe place for an individual to express emotions, feelings, and concerns without hesitation. Before the session began, a discussion of a mandala occurred. The researcher explained the benefits of a mandala and talked with the individual about what she would place inside of it. Media available included the mandala shaped canvas, brushes and water, paper towels, watercolors, and tempera paints. Themes Apparent themes stemming from the fourth art therapy session included fear, the presence of a watchful and judging figure, walls of depression, the ‘blues,’ and images of blood. Conclusion The art therapy session was successful in that the participant accomplished the task of painting a mandala-shaped canvas. In addition, Belle included her personal symbol. However, the researcher felt that the imagery produced was disturbing compared to her previous artwork (see Appendix B). The symbols used in this painting evoked fear and anxiety in the participant. The researcher provided closure, but felt that Belle was still experiencing the anger
39 portrayed in the painting. Therefore, after the session concluded, the researcher suggested that Belle should see her therapist that day to talk if needed.
Participant 2
Kate Participant 2 (Kate, pseudonym) is a 30-year-old white female diagnosed with schizophrenia, undifferentiated type. The following information was obtained through a treatment summary from her current therapist, with her permission. Background Kate was raised in Canada, later moving to the United States during her childhood years. She relocated to the southern part of the United States during her adolescence. Her educational background includes graduation from high school and one year of college. Kate is divorced and has one child with whom she has little contact after she lost custody to her ex-husband. Kate is currently employed part-time and receives mental health disability. Presenting Problems Kate has been mentally ill since her early twenties. She presented to therapy on 05/09/01 after a change in her mental health services. Her psychiatric problems include depression, anxiety, paranoia, auditory hallucinations, suicidal ideation and gestures, and multiple hospitalizations. She has a history of post- partum depression, which was her first episode of mental illness at age 21. Kate’s current therapy includes the utilization of art therapy interventions. Kate has been introduced to symbols in art therapy previous to this research study. Prior to the study Kate had formed the symbol of a snake to represent her depression. Psychosocial Stressors Kate’s primary psychosocial stressors include problems with her primary support group and occupational problems. Kate recently lost custody of her child due to a decline in daily functioning. Therefore, she often worries about her daughter and feels the need to visit. This results in additional stress as Kate is
40 unable to drive due to her mental health problems, and arranging transportation for visits proves difficult. Kate has a part-time job but often misses work due to her lack of motivation. In addition, she experiences problems relating to her family members, which creates a lack of support that Kate needs to function adequately. Medication She is currently taking an atypical antipsychotic drug to control her psychotic symptoms. Goals and Initial Treatment Plan As noted in the treatment summary supplied by the research facility, Kate’s treatment goals include increasing mood stabilization, decreasing symptoms of depression, increasing self-esteem and self-concept, education concerning her diagnosis and symptoms, and improving her parenting skills.
Table 2 DSM-IV-TR Diagnostic Information
AXIS I 295.90 SCHIZOPHRENIA, UNDIFFERENTIATED TYPE AXIS II 301.6 DEPENDENT PERSONALITY DISORDER AXIS III ASTHMA, OBESITY AXIS IV PROBLEMS WITH INTERACTION WITH FAMILY MEMBERS AND OCCUPATIONAL PROBLEMS AXIS V 35
Session 1 The initial session began by informing the participant about her rights as a research participant, the potential harm involved as well as the potential benefit, and the signing of the approved informed consent document. Quantitative Measures After the consent form was signed, the researcher began with the first measure of language production. The researcher gave clear directions to Kate
41 about the test, and then the researcher asked if she was ready to begin. Kate appeared apprehensive but ready to start. Kate was asked to do the best she could on the tests. After the verbal fluency tests were completed, the participant appeared ready to begin the next test. For a complete transcript of this measure, please see Appendix C. Qualitative Measures Next, the researcher informed the participant that she would be asked one question at the beginning of every art therapy session. The researcher then posed the inquiry to Kate: “Tell me about your day.” Kate responded with minimal exertion of effort. Her speech at times was difficult to understand and she often mumbled. Her voice was low and soft. The researcher then escorted the participant to an adjacent room that would be used for the art therapy sessions. For a complete transcript of this measure, please see Appendix C. Art Therapy Directive The researcher began the art therapy session by asking Kate if she liked art. Kate responded that she liked to paint but sometimes did not like to engage in art making at all. The researcher then asked Kate if she had ever done a scribble drawing. Kate stated that she did when she was a child. The researcher then informed the participant of the aim of the session: to create a scribble drawing. The researcher asked Kate to close her eyes, if she felt comfortable doing so, so that she would not see her scribble until it was complete. Kate responded by closing her eyes and stating that she was ready to begin. The researcher then asked Kate to begin scribbling on the paper provided. The researcher stopped Kate after a large portion of the page was covered with a scribble. Kate was then instructed to place the piece of paper on the ground and to walk around it, looking for an image to pop out of the scribble. The researcher assisted the participant by turning the picture in different directions so that she might see the picture from different perspectives. Kate stated that she could see nothing other than a snake. The researcher then asked the participant to take the paper back up to the desk and to embellish the image she saw within the scribble. The participant was given a variety of two-dimensional materials to use
42 including markers, pencils, colored pencils, and pens. Kate quickly outlined the image of the snake with a brown marker and then added the snake’s tongue in red marker. A discussion ensued about the snake and how Kate felt about it. Themes Themes that were presented during the first art therapy session with Kate included the symbol of the snake representing her depression, fear of the snake, and dislike of the snake. These themes were derived from the participant’s verbal description of the artwork. Conclusion The first session with Participant 2 was successful in that the aims of the session were completed. However, the researcher noticed that Kate lacked motivation and interest in the activity and invested minimal effort while creating the scribble drawing. Yet, the researcher was surprised when Kate stated that a snake was a symbol of her depression. It appeared that Kate had a capacity for symbolization from the first art directive.
Session 2 Session 2 included the qualitative measure “Tell me about your day,” viewing of the artwork made the previous week, the art therapy intervention, and processing of the finished product. Qualitative Measures The second art therapy session began as the researcher asked the participant to “Tell me about your day.” Kate responded with an insight into other problems affecting her, including her asthma. Her response was minimal and similar in depth to her first qualitative measure. For a complete transcript of this measure, please see Appendix C. Art Therapy Directive The researcher began the session by asking Kate if she knew what a symbol was. She stated that a symbol was something that represents something else. A discussion ensued between the researcher and the participant about symbols, including symbols that she might see or use everyday in her life. Next,
43 the researcher asked her to think about what a personal symbol might be. She stated that it she did not know. The researcher stated that a personal symbol is a symbol that represents oneself. The researcher then asked Kate to begin brainstorming what her personal symbol might be. Kate stated that she did not know and seemed unwilling to try to think of one. The researcher gave her a piece of paper and pen and suggested that she think of things that she liked or associated herself with. Kate had difficulty with this. After a few minutes, she mentioned an animal. The researcher then asked her what animal she night be like. Within a few minutes, Kate decided that she would be a teddy bear. Next, the researcher gave Kate a piece of paper and asked her to draw the symbol of the teddy bear. Kate asked if she could use a stuffed animal in the room as a model, to which the researcher responded that she could. The first image Kate produced was not satisfactory to her and she asked for another piece of paper. A second attempt at the symbol proved successful and Kate was happy with the picture of the teddy bear. She stated that a teddy bear was cuddly and caring as she described herself. Themes The themes that appeared during the session included the symbol of the teddy bear, the hope that others would see her as having characteristics like a teddy bear, and fear that they would not. These themes were derived from the participant’s verbal description of her artwork. Conclusion At the onset of the session, Kate had difficulty with the directive, but soon found a personal symbol to her liking. The teddy bear represented a warm, caring, and cuddly person who she felt she was like. Therefore, the session was successful as the task was accomplished.
Session 3 Session 3 included the qualitative measure “Tell me about your day,” viewing of the artwork made the previous week, the art therapy intervention, and processing of the finished product.
44 Qualitative Measures The session began with the researcher asking Kate “Tell me about your day.” Kate was unresponsive at first and later gave a short answer to satisfy the requirement. Her attitude appeared low and her motivation minimal to participate in the session. For a complete transcript of this measure, please see Appendix C. Art Therapy Directive The art therapy directive for session 3 was transforming the personal symbol made in Session 2 into a three-dimensional object. The researcher began by informing the participant of the directive. Next, the researcher asked Belle what materials she would like to use. Media available included clay, plasticine, pipe cleaners, tape, glue, markers, colored pencils, and pens. The participant stated that she would like to use clay. Kate began the art directive by taking yellow clay from its container and rolling it into balls. Two balls quickly began the body of the teddy bear, and four others became its legs and arms. Next, Kate added blue clay for the eyes and nose of the teddy bear. Lastly, she added a facial expression. Soon after applying the mouth Kate took it back and molded it into a smile. After Kate stated that she was finished with her symbol, processing of the artwork began. Themes Themes from the third session included the symbol of the teddy bear, the smile placed upon the face of the bear, and a sense of accomplishment. Conclusion This session was successful in that the participant completed the directive of transforming her two-dimensional symbol of a teddy bear into a three- dimensional object. Kate appeared please with herself and satisfied with the final product.
Session 4 Session 4 included the qualitative measure “Tell me about your day,” viewing of the artwork made the previous week, the art therapy intervention, processing of the finished product, and verbal fluency testing.
45 Qualitative Measures The researcher began the session by asking the participant “Tell me about your day.” Kate responded with minimal dialogue and a soft, low voice. For a complete transcript of this measure, please see Appendix C. Art Therapy Directive The art therapy directive for the fourth and final session was a mandala painting. In the painting, the participant was asked to fill it however she chose, but to reflect on the past four weeks, and to include her personal symbol if it was appropriate. As aforementioned, the researcher utilized this directive to calm and ground the participant. The researcher discussed with Kate the benefits of the mandala and that as the mandala is a circular shape, there is no beginning and end. Therefore, whatever is put inside the mandala can not escape. Kate began her mandala by using watercolors to form grass, a sun, a bear, and a snake. She had to extend the grass so that the bear could stand atop of it, at the entrance to his cave. At the end, she inserted clouds into the sky by using glitter. Themes Themes that presented themselves during the final art therapy session included an impending battle between the teddy bear and the snake, the hopeful victory of the teddy bear, the cave where the bear retreats, and an uncertain future. Conclusion The final session of the research project was successful in that the participant completed the art directive of creating a mandala painting. Kate stated that she liked her painting and hoped to hang it on a wall in her home.
Summary
The previous chapter followed the case presentation of the two research participants, Belle and Kate. Within the case presentations, the participants were described in regards to background, presenting problems, DSM-IV-TR diagnoses, as well as an outline of each session. Discussion of the artwork in
46 terms of the visual imagery, including discussion of the symbols and themes within, will be discussed in further detail in Chapter 5.
47
CHAPTER 5
RESULTS
Introduction
This chapter displays and analyzes the data collected during the research project. Data collected included participant artwork and language production data, which included phonological and semantic fluency tests, as well as qualitative responses to the query: “Tell me about your day.” Tables and charts of the language production data are presented for review. The results of the study were formulated based upon the participant data collected in a four week period. Participants were tested on measures of verbal fluency, including phonological fluency, semantic fluency, and spontaneous speech. The limitations of this study prevent the use of statistical analysis on the measures collected. There were not enough participants to formulate statistical measures on the data collected. Therefore, tables and charts were created to view the results easily.
Measure 1
Measure 1 consists of the phonological fluency test designed by Goldberg, Aloia, Gourovitch, Missar, Pickar, and Weinberger (1998). Each participant was given 60 second increments in which to name as many words as possible that
48 began with the letters f, s, and a. The responses were timed to ensure that the proper length of time was given to respond to each prompt and tape recorded to ensure accuracy and rule out experimenter error. Repetitions, perseverations, proper nouns, and repetitions of a word root, or words that began with a letter other than the one specified were disqualified from the tabulation. In addition, incoherent words were excluded from tabulation and are noted upon occurrence.
Measure 2
Measure 2 consists of the semantic fluency test designed by Goldberg, Aloia, Gourovitch, Missar, Pickar, and Weinberger (1998). Each participant was given 60 second increments in which to name as many words as possible that were in the categories of animals, fruits, and vegetables. The responses were timed to ensure that the proper length of time was given for each category to respond and tape recorded to ensure accuracy and rule out experimenter error. Perseverations, repetitions, and out of category words were excluded from tabulation. In addition, incoherent words were excluded from tabulation and are noted upon occurrence.
Measure 3
Measure 3 is the query asked at the beginning of each art therapy session. The query was: “Tell me about your day.” The researcher chose this question as it measures participants on spontaneous speech. In its nature, the question is open-ended and allows the participant to talk as long as she desires. The researcher felt this question did not intentionally provoke any intense or emotional content unless the participant decided to verbalize such content. In addition, the query is a common and ordinary query, which is not unusual for a stranger to ask another individual. The researcher felt that for these reasons, this query would be satisfactory judgment of the participant’s spontaneous language production on a day-to-day basis.
49 Participant 1
Quantitative Data For a complete of Belle’s language production results, please see Appendix B. In Table 11 (see Appendix B) the word “Ford” was excluded, as it is a proper noun, as well as the word “Susie” and “Smith.” In addition, the word “Anxious” was excluded in tabulation, as it shares a root word with “Anxiety,” which was spoken first. In Table 12 (see Appendix B) the following words were excluded from tabulation: “Fruitcake” and “Shae.” The word “fruitcake” was excluded from tabulation as it shares a root word with “fruit.” The word “Shae” was excluded, as it is a proper noun.
Comparison Data The following tables provide numerical information of the language production data collected during the research project. The tables contain data from the pretest and posttest of the verbal fluency measures.
Table 3 Participant 1 Pre-test and Post-test Results 1 Measure 1: A, S, F
A S F TOTAL
PRETEST 9 2 3 14
POSTTEST 5 3 4 13
50 Table 4 Participant 1 Pre-test and Post-test Results 2 Measure 2: Animals, Fruits, Vegetables
A F V TOTAL
PRETEST 9 4 3 16
POSTTEST 9 7 7 23
The following charts provide visual information graphing the changes observed in the language production measures collected during the research study.
Table 5 Participant 1 Phonological Fluency Comparison Participant 1
Pre-Test and Post-Test Measures
10 8 6 MAY 18TH 4 JUNE 8TH
Produced 2
Number of Words 0 FAS Phonological Fluency
In the above chart, Belle showed progress in two out of three categories. In the “A” category, Belle increased her phonological fluency by one word. In the “S” category, her fluency increased by two words. However, Belle decreased in her fluency in the “F” category by four words. The number of excluded words included four words from the pre-test and two words from the post-test, which combine for a total of six words excluded from tabulation.
51
Table 6 Participant 1 Semantic Fluency Comparison Participant 1
Pre-Test and Post-Test Measures
10 8 6 MAY 18TH 4 JUNE 8TH
Produced 2
Number of Words 0 ANIMALS FRUITS VEGETABLES Semantic Fluency
In the above chart, Belle increased her semantic fluency in two categories, and maintained her score in the other. In the “Animals” category, Belle produced the same number of words in the pre-test as well as the post-test. In the “Fruits” category, she increased her fluency by three words. In the “Vegetables” category, she increased her fluency by four words. No words were excluded in either measure.
Qualitative Data For a complete transcription of Belle’s language production results, please see Appendix B. In Measure 3A, Belle’s speech errors included fragmented speech, flight of ideas, pressured speech, and repetitions. In Measure 3B, speech errors present in the above text include fragmented speech and repetitions. In Measure 3C speech errors included fragmented speech. In Measure 3D speech errors included repetitions and flight of ideas.
Artwork The artwork produced during each art therapy session is discussed in reference to the themes in the artwork as well as the interpretations made by the researcher. For a complete reference of all artwork, please see Appendix D.
52
Scribble Drawing Please refer to Figures 3, 4, and 5. Belle’s initial scribble is linear in quality and colored in blue marker. The linear strokes are medium in pressure. When Belle was asked to find an image in the scribble, she chose to encapsulate the scribble with an image in red marker. Consequently, the image became an outline of a female figure, with blue scribbles inside. She stated that she was the figure depicted. As the researcher and participant talked about the image Belle stated “I would put tears in it if I could.” The researcher encouraged Belle to insert tears if she wished, which she did with black marker and black oil pastels. During processing, Belle stated that “They’re black because they hurt, and they are on the inside where it is dark…and I am sorry I am so sad.” In addition, she spoke about the body of the figure, which she described as heavy, shaky inside, full of guilt, and lacking direction. Her drawing is an accurate depiction of how she sees herself. She sees what is on the inside; the shaky torment of sadness and guilt overshadow the image of the person. The visual imagery depicted in Belle’s scribble drawing insinuated themes including a loss of direction in life, a need for escapism, the sadness and depression in her life (as noted by the insertion of black tears), the guilt she carries with her, and her inability to allow her feelings escape outside of her body. Personal Symbol Drawing Please refer to Figures 6 and 7. Belle’s personal symbol drawing is a wavy, red line with arrows protruding in different directions from the central line. Belle spent less than five minutes on the entire drawing, showing minimal investment in the process. She stated that she chose the color red because, to her, it means fast and exciting. The line depicted is wavy, in contrast to a straight line, as Belle stated that “straight lines are boring.” The arrows represent the different choices Belle can make in her life. After watching Belle create her personal symbol, her depiction appears accurate. It is interesting to note the push and pull quality of the central line. In its orientation, it is straight up and
53 down, but it appears as if it is being pulled in two separate and distinct directions. The arrows seem to reflect the lack of definitive direction or certainty in her life. The use of the color red may reflect her dangerous lifestyle. The themes that emerged from this piece of art include a lack of direction in life, the danger and fear she feels, the mistakes she has made, and a general sense of uncertainty. Personal Symbol Sculpture Please refer to Figures 8 and 9. The sculpture that Belle made has similar qualities to her personal symbol drawing. In a sense, Belle’s personal symbol sculpture is more two-dimensional than three-dimensional. Yet, Belle spent a significantly greater amount of time on this piece than she did her personal symbol drawing. She chose to use red pipe cleaners to form the central line of her symbol and asked for paper to glue it down on. Belle wanted to emphasize the arrows and chose to make them out of glue so that they would stand out from the page. She later put red paint on top of the glue to give the arrows color. As this piece of art is extremely similar to the personal symbol drawing (Figures 6 and 7), the same themes apply. However, the use of the pipe cleaners and glue gave the picture a different quality. The arrows in conjunction with the use of the pipe cleaners presented them as devil’s tails. This is a quality that is not apparent in the personal symbol drawing. However, in the development of her personal symbol, the symbol itself manifested strength not apparent in the personal symbol drawing; the image becomes bolder and more powerful. The personal symbol appears strong and stable, able to withstand outside pressure. The composition of the symbol suggests an interesting and dynamic quality with the directionality suggested by the arrows. Overall, the personal symbol sculpture is powerful, more so than the personal symbol drawing. Mandala Painting Please refer to Figures 10, 11, and 12. The mandala painting that Belle created exudes a sense of hopelessness, helplessness, and fear. The image presents itself as rather disturbing. At the top of the painting, Belle created a pair of eyes, which she stated were the eyes of an angry God. The blue semicircular strokes represent Belle’s sense of struggling through “the blues.” At the bottom of
54 the painting are images caged in by a thick, black line that acts as a wall. Belle is the circular figure at the bottom of the canvas, with two black eyes and a red “X” painted on top. In the center of the painting is Belle’s personal symbol, which emanates from the black cage up to the eyes. During processing, Belle stated what each aspect of the painting represented. For example, the black cage is “feeling trapped,” the brown marks within the cage are snakes and monsters, the orange marks on the sides of the painting are lightning bolts, and the red drips are her blood. Belle was asked where she was in the painting and she stated that she was “At the bottom right now. I have to break through the depression (the black walls).” This image is the most introspective of Belle’s work thus far. It seemed that this was the first time she actually admitted how she felt to someone else. In the first session when she made the scribble drawing, she alluded to the fact that she keeps all of her feelings to herself. It was in this mandala that she let someone else in. The themes that appeared from this imagery include the hopelessness and helplessness Belle experiences, the path (her personal symbol) that she must take to get out of the depression, the layers of things she must go through to get out of her mental illness, and her perception that God is angry with her.
PARTICIPANT 2
Quantitative Data For a complete transcription of Kate’s language production results, please see Appendix C. In Measure 1A (Table 7) one “S” word spoken was incoherent. In addition, the word “Sam” is categorized as a proper noun. Therefore, both words were excluded from tabulation. In Measure 1B (Table 9), one “F” word was excluded as it was incoherent.
55 Comparison Data The following tables provide numerical information of the language production data collected during the research project. The tables contain data from the pre-test and post-test of the verbal fluency measures.
Table 7 Participant 2 Pre-test and Post-test Results 1 Measure 1: A, S, F
A S F TOTAL
PRETEST 3 0 4 7
POSTTEST 6 0 4 10
Table 8 Participant 2 Pre-test and Post-test Results 2 Measure 2: Animals, Fruits, Vegetables
A F V TOTAL
PRETEST 8 6 4 18
POSTTEST 4 1 8 13
56 The following charts provide visual information graphing the changes observed in the language production measures collected during the research study.
Table 9 Participant 2 Phonological Fluency Comparison Participant 2
Pre-Test and Post-Test Measures
8
6 MAY20TH 4 JUNE6TH
Produced 2
Number of Words 0 FAS Phonological Fluency
In the above chart, Kate showed progress in one category and showed no change in the other two categories. Kate increased her phonological fluency in the “F” category by three words. However, in the “A” category, she did not name any words, which was static from the pre-test. In the “S” category, Kate maintained her pre-test score of four words. The words excluded (due to repetitions, use of a root word, and proper nouns) include two words from the pre-test and one word from the post-test, which combine for a total of three words excluded from tabulation.
57 Table 10 Participant 2 Semantic Fluency Comparison Participant 2
Pre-Test and Post-Test Measures
10 8 6 MAY20TH 4 JUNE6TH
Produced 2
Number of Words 0 ANIMALS FRUITS VEGETABLES Semantic Fluency
In the above chart, Kate’s semantic fluency decreased in two out of three categories. In the “Animals” category, her fluency dropped by four words. In the “Fruits” category, her fluency dropped by five words. However, she increased her fluency in the “Vegetable” category by four words.
Qualitative Data For a complete listing of Kate’s language production results, please see Appendix C. Kate’s third measure of language production (Measure 3A) included speech errors evident in her processes of verbalizing her thoughts. For example, Kate demonstrated incoherent phrases, alogia (poverty of content of speech), and extreme concrete thinking. In Measure 3B Kate displayed speech errors including incoherent phrases, alogia (poverty of content of speech), and concrete thinking. In Measure 3C Kate displayed speech errors including alogia (poverty of content of speech). In Measure 3D Kate displayed speech errors of alogia (poverty of content of speech).
Artwork The artwork produced during each art therapy session is discussed in reference to the themes in the artwork as well as the interpretations made by the researcher. For a reference of all artwork, please see Appendix E.
58 Scribble Drawing Please refer to Figures 13, 14, and 15. Kate’s initial scribble is controlled and is rendered in orange marker. When Kate was asked to find an image in the scribble, she stated “All I can see is a snake.” Kate outlined the image of the snake with brown marker and gave it two brown eyes and a red, forked tongue. The figure of the snake is twisted over itself and the tail ends near the head of the snake. The body of the snake is not colored in. During the processing of this piece, Kate stated that the snake was a symbol of her depression. Her physical response to the drawing was one of anxiety and fear. The themes that appeared during the art therapy session included the snake as a symbol of her depression, Kate’s fear of the snake, and Kate’s inability to accept the snake as part of her. Personal Symbol Drawing Please refer to Figure 16. Kate’s personal symbol drawing is an image of a teddy bear. The teddy bear is depicted in brown oil pastel, drawn with light to medium pressure. The bear’s expression lacks any emotion and may be perceived as sad or unhappy. The appendages of the bear are rather disconnected and compartmentalized from the image as a whole. This translates to a loosening of associations in the visual imagery of the personal symbol, which correlates to Kate’s loosening of associations in spontaneous speech. Kate chose the symbol of the teddy bear as she characterized it as loveable, soft, and cuddly. The image was drawn rather quickly, and Kate did not expend much effort in making it. However, she was satisfied with the final product. The symbol of the teddy bear insinuates Kate’s desire to be brave and victorious in life. Due to her mental illness, Kate often presents herself as weak and fragile, which is paired with a low self-esteem and low self-concept. Therefore, this symbol may be seen as one of wish-fulfillment. Personal Symbol Sculpture Please refer to Figures 17, 18, 19, and 20. Kate’s personal symbol sculpture is that of a teddy bear. The bear was made out of yellow, blue, and red plasticine clay. Kate made the body of the bear first, and later added facial features and appendages. In contrast to her personal symbol drawing, the facial
59 expression of the sculpture of the teddy bear reveals a smile. The eyes and nose are pieces of blue plasticine clay rolled into balls. The sculpture alludes to Kate’s desire to be happy and content in her body. Mandala Painting Please refer to Figures 21 and 22. Kate’s mandala painting depicts a scene of a landscape with a snake and bear in the foreground. The sky region is painted in a blue watercolor, which also includes a bright, yellow sun and sparkly white clouds fashioned with glitter. The bear is colored brown and stands on a rock in the entrance area of a cave, where the bear lives and hides from the snake. The snake is a large, purple image complete with a purple glitter eye, slithering its way towards the cave. Kate implied that the snake and the bear were going to fight. The painting appears cheery and nice as the fight has not yet begun. In this piece, the snake appears larger than the bear; the tail of the snake is not depicted, but is suggested to be off the canvas. During processing, Kate stated that she wanted the bear to win the fight. This picture represents Kate’s internal struggle with her depression.
Comparison of Language Production Data
Comparing the verbal fluency testing of both participants may lead to insight of the inherent differences in language between schizophrenia and schizophreniform disorders. The results of the verbal fluency testing (Measures 1, 2, and 3) recorded during each art therapy session will be compared between the participants. For a complete reference of the results discussed, please refer to Appendices B and C, as well as tables listed previously in Chapter 5.
Measure 1 In Measure 1, Belle displayed a decrease in phonological fluency. In the “A” category, Belle’s results decreased by four words from pre-test to post-test. In the “S” category, Belle increased fluency by one word. In the “F” category, Belle decreased by one word. Overall, Belle’s total tabulation reveals a decrease in
60 phonological fluency by one word. In the same measure, Kate displayed a moderate increase in phonological fluency. In the “A” category, Kate increased her fluency by three words. In the “S” category, she failed to produce any words beginning with the letter “S” in both the pre-test and in the post-test. However, in the “F” categories, Kate’s fluency remained static. Overall, Kate’s total tabulation reveals an increase of three words from pre-test to post-test. In comparing the totals of the two participants, Kate’s fluency increased more so than Belle, who decreased in phonological fluency. Measure 2 In Measure 2, Belle displayed an overall increase in semantic fluency. In the “Animals” category Belle’s fluency remained static. In the “Fruits” category she increased in fluency by three words. In the “Vegetables” category Belle increased in fluency by four words. In total, Belle gained fluency in Measure 2 by seven words. This reveals a significant increase in fluency between the pre-test and post-test measures. Kate displayed a significant increase in semantic fluency as well. In the “Animals” category she increased in fluency by four words. In the “Vegetables” category Kate increased by four words as well. However, in the “Fruits” category, Kate decreased in semantic fluency by five words. In total, Kate gained fluency in Measure 2 by five words. In comparing the two participants, Belle’s fluency increased more so than Kate’s fluency. Measure 3 The data produced from Measure 3 reveals differences in the spontaneous speech of each participant. In comparison to one another, Belle’s responses were more in depth and lengthy than Kate’s responses. In the majority of Belle’s responses the researcher was given insight into her feelings and emotions of what transpired on the particular day in question. On the other hand, Kate’s responses were on a superficial and surface level, revealing minimal insight into any aspect of herself. For example, Kate’s responses were extremely concrete and lacked informative knowledge when compared to Belle’s responses. In addition, even though this measure was not tabulated for length, Belle’s responses were significantly longer than Kate’s responses.
61
Comparison of Artwork
Comparing the artwork of both participants may lead to insight of the inherent differences between schizophrenia and schizophreniform disorders, as well as the differences in the artwork produced by those individuals. The artwork produced during each art therapy session will be compared between the participants. For a complete reference of the artwork discussed, please refer to Appendices D and E.
Scribble Drawing Please refer to Figures 3, 4, 5, 13, and 14. The most evident difference between the participants’ drawings is the manner in which the image of the scribble was perceived by the artist. Belle chose to encapsulate the scribble to find an image, whereas Kate chose an image within the scribble. The image Belle perceived in the scribble was an image of herself and a representation of how it feels to be her. Kate’s image in the scribble was a representation of something she fears: her depression. Belle’s image was perceived as an internal symbol. On the other hand, Kate’s image was perceived as an external symbol; she felt that her depression was an entity outside of herself.
Personal Symbol Drawing Please refer to Figures 6, 7, and 16. The personal symbol drawings by each participant in the research study are extremely different. Compositionally, one is abstract (Belle’s) while the other is representational (Kate’s). Belle’s personal symbol evolved from an abstract idea, a wavy line with arrows protruding from various points on the line. Kate’s personal symbol is a representation of a teddy bear, drawn from a stuffed animal model. However, both symbols contain aspects that the participant felt characterized themselves. Both Belle’s and Kate’s drawings were rendered with medium pressure and minimal effort. However, they are exceptionally different. Belle’s symbol is seen
62 as more stable and strong than Kate’s as it contains a symmetrical balance and appears to contain stability. Yet, it is interesting to note that Belle felt her symbol was weak, chaotic, and lacking a definitive direction. On the other hand, Kate’s drawing is a disconnected series of parts that put together through perception becomes the figure of a bear to the observer. Therefore, one could argue that Belle’s symbol is more developed than Kate’s. Personal Symbol Sculpture Please refer to Figures 8, 9, 17, 18, 19, and 20. Again, both participants’ sculptures are different from one another. The most obvious difference is the dissimilarity in the forms of each sculpture. Specifically, Kate’s sculpture is a three-dimensional object, while Belle’s is more of a two-dimensional relief. Kate’s sculpture can be viewed in-the-round, while Belle’s can only be viewed from a single, frontal orientation. This aspect of the sculptures suggests that Kate accomplished the task more so than Belle did, as the directions were to create a three-dimensional representation of the personal symbol drawing produced in Session 2. However, Belle’s sculpture appears as more stable and powerful than Kate’s, as it is a solid form. Kate’s sculpture is a composition of disconnected parts created by molding different pieces of clay together and sticking them to one another. Mandala Painting Please refer to Figures 10, 11, 12, 21, and 22. Both of the mandala paintings are extremely different from one another. Belle’s painting is an abstract compilation of symbols that speak to the system of her depression and anxiety. Kate’s painting is a representational depiction of a future battle between her personal symbol and the symbol of the snake, which represents her depression. Aesthetically, Kate’s painting appears to depict a warm and sunny day complete with sparkling clouds. However, the subject matter of the painting reveals a struggle between good and evil. Belle’s painting is aesthetically displeasing; one may feel provoked and anxious when viewing the painting. Yet, this painting reveals a struggle as well; the struggle is between Belle’s personal symbol and depression, anxiety, guilt, and fear. In this manner, the paintings are similar. The
63 depth of the symbols presented in each painting reveals that Belle’s is more richly symbolic than Kate’s.
Summary
The previous chapter included a detailed discussion of the results of the research study. Verbal fluency results were measured and compared between the participants’ pre-tests and post-tests. The visual imagery of the artwork produced during each art therapy session was explored. For a complete reference of the language production results, please see Appendices B (Participant 1) and C (Participant 2). For a complete reference of the artwork mentioned in this chapter, please see Appendices D (Participant 1) and E (Participant 2).
64
CHAPTER 6
SUMMARY AND DISCUSSION
Introduction
The following chapter incorporates the progress of the participants, recommendations for future treatment, theoretical and clinical considerations, interpretations of the results, limitations of the study, implications for future research, and the study’s contributions to the field of art therapy. The participants were involved in a series of art therapy sessions, focusing on symbolization, for a period of four weeks to gain insight into the language production capabilities of the individuals.
Progress of Participants
The progress of the participants is noted in the increase seen in producing a symbolic language through the creation of personal symbols during the research project. Progress can also be noted in the personal awareness of each participant to feelings and emotions in relation to mental illness, as stated in the consent form. However, the progress made in the areas of language production is more difficult to interpret. Specifically, the length of the treatment intervention was too brief to cause noticeable changes in the language production data. In consideration of the progress of each individual, both participants gained significantly from this experience. In particular, both participants were
65 able to increase their own awareness as an individual living with a mental illness. Increasing the symbolic language of each participant allowed them to explore themselves in another dimension and hopefully express themselves better to people around them. In particular, Kate progressed in her ability to understand her life in a symbolic manner. Therein, Kate stated that she wanted her personal symbol of the teddy bear to triumph over her symbol of the snake, which represented her depression. However, in the area of language production, Kate did not progress significantly. In observing her spontaneous language production, she was similar to Frith’s (1997) description of the observations of individuals diagnosed with schizophrenia (absence or poverty in the rate of speech, content, and accompanying gestures). Throughout her quantitative measures, Kate displayed a lack of content of speech, accompanying gestures, and the speech was often incoherent and mumbled. Belle progressed in her ability to communicate through symbols. However, there appears to be much work that Belle will have to do to overcome the guilt and depression that plagues her. It appeared that the research project revealed a multitude of issues that Belle had not been aware of previously. Some might think that she regressed in this manner, but now there is more that she is conscious of that she can work on with her therapist.
Recommendation for Future Treatment
The participants of this study were given the suggestion to continue treatment. In addition, it was suggested to the primary therapist to continue with the direction of the progression of the personal symbols produced during the art therapy sessions. It appeared that both individuals would benefit from group counseling and family therapy. Group counseling would offer each individual to meet and talk with others who share similar lifestyles. For Belle, group counseling related to substance abuse would be valuable, while Kate would gain
66 from a parenting group. Due to the similarity of each participant’s family problems, it would be constructive for the family to be involved in therapy as well. In particular, Kate would greatly benefit from continued therapy. At this point Kate is beginning to view her mental illness as something she may be able to live with instead of something that she suffers from. In her state of mental illness, it is likely that a cessation of treatment would result in a diminished capacity of functioning. It was recommended that Belle continue treatment utilizing the personal symbols created during the research project. The symbols Belle created were powerful and insightful, which might prove to be a beneficial direction for her treatment plan. Theoretical and Clinical Considerations
The researcher utilized art therapy directives created in conjunction with the theories of Lusebrink (1990). Lusebrink stated that a therapist should utilize different levels on the ETC to elicit symbolic formation and communication. In the first directive, the directive was on kinesthetic and perceptual levels. In the second session, the directive moved the participant up to the cognitive and symbolic levels. In the third session, the kinesthetic and sensory levels were used to create three-dimensional symbols. Lastly, the fourth session utilized the cognitive and symbolic levels to create mandala paintings, as well as the creative level. By manipulating the different levels of the ETC, the aim was for the participants to improve in language production capabilities. It appears, however, that the treatment intervention was too short to reveal any significant changes in language production data. In addition, the researcher utilized the theories of symbolism and art therapy developed by Wilson (2001) to formulate the research question of this study. The researcher surmised that utilizing art therapy interventions with individuals diagnosed with schizophrenia and schizophreniform disorder would improve the individual’s ability to symbolize. The visual images produced during the art therapy sessions, along with the symbols created therein, led to a greater
67 conscious awareness of the individual. It was apparent during the course of this study that both participants, Belle and Kate displayed key symbols early on that continued to the end of the study with a gradual recognition of their meaning, developing to powerful and personal symbols. It appears that the distance that art allows between the individual and the conflict that the symbol represents was beneficial. Cohen (1981) stated that typical symbols produced by individuals diagnosed with schizophrenia are related to aggression, regression, fear, anxiety, and sexual conflict. In relation to Cohen’s theory, both participants’ artwork and the symbols within may be explored in greater detail. Belle’s symbols (abstract personal symbol, the eyes of God, monsters, snakes, and lightening bolts) were related to anxiety and fear. Belle stated that God was angry with her for the decisions she has made and was scared of him. The snakes and monsters housed inside the walls of depression with Belle produced high levels of anxiety. Kate’s symbols (the snake and the cave) were related to fear, anxiety, and regression. The cave symbolized the teddy bear’s frequent regression into a state of hopelessness. The snake represented the fear and anxiety Kate felt towards her depressive episodes.
Interpretation of Results
The quantitative results of the study were inconclusive to the language production capabilities between the two disorders. Tabulation of the verbal fluency measures revealed inconsistencies in language production capabilities of each participant over time. Therefore, it may be inferred that situational circumstances produced the changes seen in the tests. Daily stressors and day- to-day changes in relationships might be the reason for the changes seen in the language production measures. Due to the limitations of the study, it is impossible to know why the changes occurred. However, it is interesting to note the differences observed between both participants in respect to the language production data recorded. Belle displayed
68 a decrease in phonological fluency (minus one) and a significant gain in semantic fluency (plus seven) from pre-test to post-test. Kate displayed an increase in both phonological fluency (plus three) and semantic fluency (plus five). However, Belle’s gain in semantic fluency (plus seven) was greater than Kate’s gain (plus five) by two words. Yet, the quantitative results of the study did produce interesting results. Specifically, the ability of the participants to create symbols during the course of the intervention was unquestionable. The researcher observed the development of major symbols in both participants’ artwork. For example, Kate’s symbol of the teddy bear evolved to the capacity where she believed it may have the strength needed to fight the snake, which represented her depression. Belle’s personal symbol evolved from an uncertain idea to a powerful symbol which accurately represented her lifestyle. Both individuals were able to create symbols that will allow them to further explore themselves in relation to their mental illnesses. In regards to the differences observed between the artistic representations of each participant, a conclusive statement can not be made. However, if one views each session and the artwork produced therein separately, comparisons reveal interesting insights. For example, in the scribble drawing Belle chose to encapsulate her scribble to reveal a shape of a woman whereas Kate chose one part of the scribble to become the snake. Belle’s personal symbol drawing and sculpture were more powerful and in depth than Kate’s. However, Kate’s personal symbol sculpture is more three-dimensional than Belle’s. Lastly, when comparing the mandala paintings of each participant, Belle’s reveals in depth and rich symbolism, whereas Kate’s painting is more superficial. Yet, both paintings reveal a struggle with mental illness.
Limitations of the Study
Major limitations to the study include the small sample size of participants. The original proposal suggested for four to eight individuals participate in the study, but the researcher experienced difficulty in finding qualified individuals
69 willing to participate in the study, as well as difficulty gaining approval for the study by governing bodies in time to complete the study. Due to this fact, conclusive results were not possible. Charts and graphs were formulated based on the data received, but statistical analysis of the data was not in the scope of this research study. This study should serve as a pilot study in comparing the language production data of individuals diagnosed with schizophrenia and schizophreniform disorder. In addition, the qualitative data collected during each art therapy session may have been influenced by a variety of factors, including daily levels of stress and anxiety, happenings within the functioning of the individual, and external forces that were inflicted upon the individual. An additional limitation to the study was the lack of availability of individuals diagnosed with schizophreniform disorder. It was difficult to find inpatients or outpatients that were classified with such a diagnosis, which is a growing trend in today’s psychiatry; yet, there is no known reason for this observation. Furthermore, many individuals may have presented with symptoms of schizophreniform disorder, but were diagnosed with other mental illnesses including brief psychotic disorder, posttraumatic stress disorder, and schizophrenia.
Implications for Further Research
If this research study were to be continued, the researcher would like to obtain a total of 60 participants for both categories (30 participants for the schizophrenia category and 30 participants for the schizophreniform category). Results of the study would be tabulated using a one-way ANOVA, paired t-tests, as well as means, standard deviations, and significance values. This study would be able to gain insight into the differences in language production between the two disorders that may reveal greater significance than the present study. In addition, it would be advantageous to match participants on varying factors
70 (presence of Axis II Disorders, symptoms of trauma, bipolar features) to aid in ruling out extraneous variables. In addition, it would be interesting to investigate the language production data for individuals at different stages in the course of their specific mental illness. For example, to monitor the language production data of an individual from the onset of schizophrenia and to continue testing throughout the course of the illness may provide interesting insights into the decompensation that schizophrenia afflicts to the cognitive functioning of an individual, including language production capabilities.
Contributions to the Field of Art Therapy
This study has significantly contributed to the research in the field of art therapy in the areas of symbols, symbolic language, and the use of art therapy to elicit language production. At this time, there has been no known research of the relationship between art therapy and language production. Therefore, this study should encourage further research in this area. It is important for art therapists to recognize the deterioration of cognitive functioning seen in schizophrenic-type disorders. In the profession of art therapy, clinicians often rely on the art to bring forth a dialogue between the client and the art therapist. However, if a client is diagnosed with schizophrenia or a schizophrenic-type disorder, the language capabilities may be impaired. Assuming that art may aid in the production of new language should encourage art therapists to identify such clients and work with them to increase their language production. Helping these individuals will assist them in other facets of their lives, including the ability to talk to various practitioners about their symptoms, needs, and concerns. This study should also encourage researchers to begin to assess the efficacy of art therapy in producing noticeable changes in various aspects of language.
71 Conclusion
Although no significant results were found in the language production data from verbal fluency testing, significant observations were made in the area of spontaneous speech (Measure 3), as the individual diagnosed with schizophreniform disorder produced significantly more language than the individual diagnosed with schizophrenia. Yet, that measure was not tabulated in terms of length of speech produced, but this finding is notable. Perhaps the area of spontaneous speech is the best measure for comparing language production output between the two disorders. However, this might be due to the personality styles of each individual. Or, it might be a characteristic of the disorder that merits further study. Additional research into the area of spontaneous speech might uncover new insights into the language production capabilities of individuals diagnosed with schizophrenia and schizophreniform disorders.
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APPENDIX A SCHIZOPHRENIA SUBTYPES AND RELATED DISORDERS
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Schizophrenic Subtypes and Related Disorders
Paranoid Type The paranoid subtype refers to a type of schizophrenia in which there is a perseveration of cognitive functioning and/or affect. The APA (2000) contends that “delusions are typically persecutory or grandiose, or both, but delusions with other themes (e.g., jealousy, religiosity, or somatization) may also occur” (p. 313). Additionally, for a diagnosis of schizophrenia, paranoid type, there must not be any symptoms of other subtypes including catatonic and disorganized schizophrenia present. Catatonic Type Catatonic schizophrenia entails a motor disturbance involving motoric immobility, excessive motor activity, extreme negativism, mutism, peculiarities of voluntary movement, echolalia, or echopraxia (APA, 2000). Such motor activity is not induced by external stimuli and is viewed as trivial. As in all subtype diagnoses, in order to reach such a diagnosis, factors including substance- induced behavior and general medical conditions must first be ruled out. Disorganized Type Historically known as hebephrenic type, the disorganized type is characterized by disorganized speech, disorganized behavior, and flat or inappropriate affect (APA, 2000). Symptoms of disorganized behavior include silliness, laughter, grimacing, and other idiosyncrasies. Undifferentiated Type The undifferentiated type of schizophrenia refers to features which present as schizophrenia, but which do not resemble any other subtype including paranoid, disorganized, or catatonic (APA, 2000). Residual Type A diagnosis of residual type schizophrenia is defined as a previous diagnosis of schizophrenia with no current positive (delusions, hallucination, disorganized speech and/or behavior) symptoms present (APA, 2000). However,
74 the persistence of negative symptoms is witnessed, which includes affective flattening, alogia, and/or alvolition. This subtype is common in an interim of the disease, whether between major episodes or during remission. Schizoaffective Disorder Schizoaffective disorder is the presence of a diagnosis of schizophrenia paired with a mood disorder (APA, 2000). The diagnosis is comprised of two types including bipolar type and depressive type. To qualify a bipolar type, the individual must exhibit symptoms of a manic or mixed episode, while the depressive type exhibits only depressive symptoms. Schizophreniform Disorder Schizophreniform disorder is classified as identical to schizophrenia with the symptoms persisting for at least a month, but less than six months (APA, 2000). This diagnosis falls between the qualifications for schizophrenia and a brief psychotic disorder.
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APPENDIX B PARTICIPANT 1 MEASURES
76 Measure 1A The measures of phonological and semantic fluency were taken on May 15, 2005. Table 11 Participant 1 Measure 1A F A S FAST ASS SMITH FORD ANXIETY SNAKE FARM ANXIOUS SAVAGE FOREST SAD FRAME SUSIE FEAR FUN FAILURE FAINT FRUSTRATION
Measure 2A Table 12 Participant 1 Measure 2A ANIMALS FRUITS VEGETABLES CATS APPLES CAULIFLOWER DOGS ORANGES GREENS RATS PEACHES GREEN BEANS SNAKES PEARS DRAGONS CHICKENS PIGS HORSES COWS
77 Measure 1B The second set of measures of phonological and semantic fluency was taken on June 8, 2005. Table 13 Participant 1 Measure 1B F A S FRUIT APPLES SNOW FANTASTIC AVACADOS SNAKES FROGS APPETIZERS SALAD FISH SOUP FLOWERS SHAE FRUITCAKES SHAMROCK
Measure 2B Table 14 Participant 1 Measure 2B ANIMALS FRUITS VEGETABLES CATS ORANGES BROCOLLI DOGS APPLES CAULIFLOWER ELEPHANT BANANNAS BRUSSEL SPROUTS GIRAFFE PEACHES ASPERAGUS HORSES PEARS LETTUCE MULES PLUMS CABBAGE LIONS AVACADOS CARROTS TIGERS BEARS
78 Qualitative Data Measure 3A: Response to the query: “Tell me about your day.” Um, it’s already been stressful. Um, I got a call from my daughter. Very angry because uh, I wouldn’t come see her today. Um, I’m concerned because she’s cut herself again and she’s busted out a window. Steven’s already called. I’ve already been invited to a party. I don’t know whether to go or not. ‘Cause I know they’re gonna be drinking there and that’s a no- no for me. And then I feel guilty about leaving Steven cause he’s not invited. And Janet, um, wanted me to clean her house today but then whenever I went over there she wanted, uh, I said what do you want me to start doing and she said well all I can think of is move the bed against the wall. So I thought that was all she wanted to do but then whenever I started to leave she says ‘Well, I guess we just aren’t…aren’t gonna get any cleaning done, are we?’ And I was just surprised. So I’m already…oh, and then I then I drew…I was trying to draw something and it turned out to look evil instead of the way I wanted it to. And that frustrated me. So, that’s my morning.
Measure 3B: Response to the query: “Tell me about your day.” Um, well, I didn’t sleep very good last night. I had a lot of nightmares and uh, so when I got up this morning I went back to bed and uh…got up and my next door neighbors um…I’ve got pretty close to but they’re moving today, so uh, I just spent a little bit of time with them this morning after I woke up and um when I get back I’m gonna spend some more time with them before they leave. Um, Steven, I think Steven wants me to do something that’s…I’m not gonna do. So I’m…was a little upset about that. But other than that I’m alright.
79 Measure 3C: Response to the query: “Tell me about your day.” Uh, not much to tell. I got up and took a friend to get some bloodwork done. And then I came home and was gonna go to sleep but then, uh, Shae called so I decided to get up, get in there, and take a shower, and come on. And that’s about it.
Measure 3D: Response to the query: “Tell me about your day.” Huh… I don’t I don’t I don’t know I’m not really sure. Um, I got some news this morning that has really upset me. I don’t know what I am going to do about it so I’m very fearful right now. And angry. So, uh, it hasn’t been a great morning. I mean that’s…I I I don’t know how to describe it.
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APPENDIX C PARTICIPANT 2 MEASURES
81 Measure 1A The following measures of phonological and semantic fluency were taken on May 20, 2005. Table 15 Participant 2 Measure 1A F A S FAT SAM FAN SAT FANTASTIC SIT SMILE SAD Incoherent Word
Measure 2A Table 16 Participant 2 Measure 2A ANIMALS FRUITS VEGETABLES CAT APPLE LETTUCE DOG ORANGE RADISHES PUPPY GRAPE POTATOES HORSE AVACADO CUCUMBERS COW BANANNAS GIRAFFE TOMATOES MONKEY ORANGUTANGS
82 Measure 1B The following measures of phonological and semantic fluency were taken on June 6, 2005. Table 17 Participant 2 Measure 1B F A S FAN SAD FAT SORRY FATIGUE STOP FAR STORY FANTASTIC FAVORITE Incoherent Word
Measure 2B Table 18 Participant 2 Measure 2B ANIMALS FRUITS VEGETABLES BEAR TOMATOES LETTUCE MONKEY CUCUMBERS ORANGUTANG RADISHES SNAKE CABBAGE PEAS CORN BEANS POTATOES
83 Qualitative Data Measure 3A: Response to the query: “Tell me about your day.” Well, I had a little…(incoherent speech)… because last night I had an asthma attack. I had a fun night. So, I’m tired. Uh, I went to group therapy this morning with the FACT team and then I came here.
Measure 3B: Response to the query: “Tell me about your day.” My day hasn’t really…(incoherent speech)… My day it just really started. Uh, I didn’t want to get up, then came over here…(incoherent speech).
Measure 3C: Response to the query: “Tell me about your day.” Uh, nothing really. I have been sick all week.
Measure 3D: Response to the query: “Tell me about your day.” Well I went to the Dollar Store and then I came over here.
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APPENDIX D PARTICIPANT 1 ARTWORK
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PARTICIPANT 1 ARTWORK
FIGURE 3 SCRIBBLE DRAWING: 05/18/05 PHASE 1
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FIGURE 4 SCRIBBLE DRAWING: PHASE 2
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FIGURE 5 SCRIBBLE DRAWING: PHASE 3
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FIGURE 6 PERSONAL SYMBOL: 05/25/05
FIGURE 7: DETAIL
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FIGURE 8 PERSONAL SYMBOL SCULPTURE: 05/31/05
FIGURE 9: DETAIL
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FIGURE 10 MANDALA PAINTING: 06/08/05
FIGURE 11: DETAIL FIGURE 12: DETAIL
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APPENDIX E
PARTICIPANT 2 ARTWORK
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PARTICIPANT 2 ARTWORK
FIGURE 13 SCRIBBLE DRAWIN G: 5/20/05 PHASE 1
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FIGURE 14 SCRIBBLE DRAWING: PHASE 2
FIGURE 15 DETAIL OF SCRIBBLE DRAWING
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FIGURE 16 PERSONAL SYMBOL: 05/23/05
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FIGURE 17 PERSONAL SYMBOL: 5/30/05
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FIGURE 18: DETAIL FIGURE 19: DETAIL
FIGURE 20: DETAIL
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FIGURE 21 MANDALA PAINTING: 6/06/05
FIGURE 22 DETAIL
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APPENDIX F APPROVAL FORMS
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104 REFERENCES
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105 Jung, C. G. (1964). Man and his symbols. New York: Dell publishing.
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BIOGRAPHICAL SKETCH Karen R. Karpick
EDUCATION Florida State University, Tallahassee, FL Masters of Sciences in Art Therapy, May 2005
College of Charleston, Charleston, SC Bachelor of Sciences in Psychology & Bachelor of Arts in Studio Art, Concentration in Drawing and Painting Minor in Art History Magna cum Laude, May 2003
CLINICAL EXPERIENCE
Apalachee Center, Inc., Tallahassee, FL Art Therapy Intern, Spring 2005 ● Established an art therapy internship site. Conducted individual and group art therapy sessions with individuals with psychological disorders participating in the Day Treatment Program, provided assessments, planned treatment, assisted with intakes, and made home visits to Day Treatment clients.
Apalachee Correctional Institution, Sneads, FL Art Therapy Intern, Fall 2004 ● Conducted group art therapy sessions with prison inmates with psychological disorders, provided assessments and planned treatment.
Ability 1st, Tallahassee, FL Art Therapy Intern, Fall 2004 ● Conducted individual and group art therapy and counseling sessions with the homeless community of Tallahassee at The Shelter, Inc. and The Day Shelter, provided assessments and planned treatment.
Southwestern State Hospital, Thomasville, GA Art Therapy Intern, Spring 2004 ● Conducted individual and group art therapy and counseling sessions with individuals with psychological disorders, provided assessments, planned treatments, participated in treatment team meetings, and planned hospital-wide therapeutic activities.
Florida State University Multidisciplinary Center, Tallahassee, FL School Counselor, Fall 2003 • Conducted individual and group counseling in Taylor and Wakulla county schools as well as administering intakes and interviews with children and parents interested in counseling for various psychological and behavioral problems.
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