Case Illustrations

Our illustrations include a pair of sisters, and an elderly male.

Personal Profile 3.3

This case involves two sisters who are resistant to visiting their biological mother. The psychosocial history reveals that the biological parents divorced when the children were toddlers. The mother quickly remarried, and the children's stepfather was physically abusive to the children as well

Art Therapy Drawing Activities
3.7 Dysthymia

as toward the mother (which they witnessed). At this point they were removed from their mother's care and placed with the biological father.

The 10-year-old (Figure 3.7) is currently experiencing difficulty concentrating, is hostile and resistant, and is overly dependent upon her father. The 8-year-old (Figure 3.8) is expressing numerous somatic complaints in the form of stomach aches and headaches as well as experiencing nightmares. A medical exam found no medical etiology to cause the somatic complaints. The assessments were conducted on the same day and separately for each child.

From a quantitative perspective the height of Figure 3.7 is exceedingly small (environment experienced as overwhelming and self as inadequate; infantile tendencies), and all the form items are drawn utilizing the bottom edge of the page as a ground line (insecurity, feelings of inadequacy). The house and tree are drawn in long strokes (apprehensive; requires support and reassurance), while the entire person (without face) is shaded and colored orange in an aggressive manner (concealment). Color usage is appropriate; however, the roof of the home (orange) matches the color utilized for the person and points toward tensional intensity (anxiety). The use of distant detailing that dwarfs the person (i.e., sun) indicates anxiety regarding environmental intrusions, with poor intellectual defenses.

Art Therapy Person Drawings
3.8 Adjustment Disorder with Mixed Anxiety and Depressed Mood

A qualitative analysis notes that the house uses the paper's edge as a ground line (basic home insecurities). It has an inverted V roof, windows that are attached to the wall edge (need for support, fear of autonomy and independent action), and a door that floats above the baseline (interpersonal inaccessibility). The chimney is detailed with cross-hatched brick (enriching detail devoid in other items) and a line of thick smoke emanates from it (inner tension). The tree is to the viewer's right and has two lines for the trunk and a looped crown (oppositional tendencies) in both brown and green. A person stands to the left of the home with outstretched arms (desire for affection), a circular face, dots for eyes, a nose, and a single line for the mouth. Overall, the lack of facial detailing gives the impression of concealment. The head is connected directly to the squared trunk (body drives threaten to overwhelm). The hair is profuse (striving) and yellow. The figure has a rectangular body with reinforced shading of the body walls (need to contain and delineate ego boundaries); however, the figure has no hands or feet (inadequacy, helplessness, withdrawal). In addition to the HTP items, distant detailing appears in the upper left-hand corner in the form of an oversized sun with large rays (need for love and support; representative of parental love), and two blue clouds float over the home (generalized anxiety).

When asked to tell something about the drawing, the patient stated that the person was her and that the house was her home where she and her sister live. Clarifying questions did not yield any further information. She titled her drawing "Me and my Home."

The symbolic abundance of ideas found within this assessment points toward significant feelings of inadequacy, insecurity, and fear in conjunction with anxiety. Her dependent reactions are in direct conflict with her need for industry and accomplishments. Moreover, the reinforcement found in the rendering of her person illustrates the struggles surrounding her sense of self. Another area of concern is the lone detailing found in the chimney. This, coupled with the thick smoke, exemplifies her overconcern with the emotional turbulence that is occurring within the home as well as the client's own inner tension.

In comparison, in the 8-year-old's-drawing (Figure 3.8) the person is within normal height, while the home is drawn tall and thin with a tiny doorway (reluctant to permit access). This, however, is normal for this client's age, when size and proportion are dependent upon emotional values rather than reality. The remainder of the drawing shows adequate line quality, strokes, shading, detailing, and use of color. There are ground lines added under both the tree and the house (provides stability and structure within the environment to reduce the stress when drawn by young children). The manner of scribbling or shading for the ground under the tree, however, bodes poorly for her ability to cope.

The house is placed to the viewer's left and is drawn tall and thin. The roof is patterned (normal use of detailing) as is the overly large chimney (exhibitionistic tendencies). A circular plume of smoke is seen escaping the home (emotional turbulence within the home). All windows are drawn high on the front of the house, and there is a tiny door (reluctant to permit access) that does not connect to the baseline (interpersonal inaccessibility). Outside the home a purple-spiked ground line is drawn (provides measure of security but also appears foreboding). An extremely tall tree (aggressive tendencies, need for dominance; feels constricted by and in the environment) is found just right of center and has a colored trunk with branches and foliage located on each branch. Under the tree is a highly shaded ground line. The person is placed on the right side with a circular smiley face (typical for age group), thin neck, and long flowing red hair, wearing a brightly colored blue dress. She has well-detailed hands, considering the use of markers and difficulty associated with drawing fingers. Her one-dimensional legs appear slightly regressed (indicative of 6-year-old); however, the addition of high-heeled shoes shows her attention to detail and focus on shoes versus the legs. Just above the home is found a sun (representative of parental love and support) wearing sunglasses with a "Charlie Brown" smile (normal for age group).

When asked to tell what was going on in this picture she said the girl was her and that she lived in the house with her sister, Dad, and her Dad's girlfriend. She titled the drawing using her own name (which has been changed): "Heather's Creation."

Not unlike her older sibling, this client is apprehensive due to the turmoil found within the home and the prospect of reestablishing visits with her biological mother. Since a medical etiology was ruled out for the somatic complaints, it would appear that she is experiencing a kinesthetic sensory system (Mills & Crowley, 1986) whereby anxiety is revealed through physical symptoms. In spite of this, the overall drawing shows good adjustment. The difference between her and her older sibling is that this child finds stability and structure within the environment, allowing her to move through the necessary stages of development. It will be important to ascertain the level of abuse that occurred, and it is possible that the younger sibling was not the primary victim of the attacks but was protected by her older sister.

In evaluating the two renderings, the 10-year-old's drawing (Figure 3.7) should show variances with regard to increased accuracy in depth, plane, detailing, and elevation (see Table 3.1). However, her drawing items appear more in keeping with a 7-year-old's with attendant expression of moodiness and anxiety. This inward thrust (see Table 2.1) keeps her tethered to feelings of shame and humiliation, and it also correlates to the age when the abuse first began. In contrast, the younger sibling shows adequate development within her artwork and an increased attention to the environment. Therefore, her adjustment parallels the use of age-appropriate intellectual defenses together with age-appropriate expansive symbolism (note size of person).

At this juncture the older sibling appears to be having a much more difficult time adjusting even though the younger sibling is experiencing a wealth of somatic issues. However, her symptoms are not merely focused on physical complaints, and this signifies an etiology focused on worry and anxiety that should resolve itself with individual and family therapy as well as ongoing structure and safety. Overall, the older child appears to be withdrawing from contact with the outside world and clinging to infantile qualities within her relationships. This indicates a lower level of functioning, increased depressive features, and the possible utilization of the defense mechanism of regression.

If we review the postdrawing inquiry, although both girls showed a paucity of response, the younger sibling placed the entire "protective" family within the home (the tiny door perhaps not allowing others within this protective circle), while the older child added only herself and her sister. This is a curious situation and makes one wonder whether the older child views herself in the role of protector yet is emotionally and physically unable to perform this role and is consequently struggling with feelings of inadequacy, guilt, and shame at her perceived failure. Additionally, this child may be harboring resentments that the father did not rescue his children and may therefore be undergoing a sense of distress that anyone can provide protection.

Overall, there are many unanswered questions that will require further exploration. However, the older child may benefit from involvement in individual, family, and group therapy to increase her contact within the environment and focus on her own feelings and issues without the younger child being the topic of discussion or concern. Due to the level of resistance, an expressive therapy approach (in individual and family therapy) may prove beneficial until she can build sufficient trust and rapport to communicate her feelings rather than repressing or regressing.

Personal Profile 3.4

The client is an elderly male who has been divorced multiple times. He presently has no contact with any of his ex-wives or family members. He states that he left home as a preteen and has lived on the streets the majority of his life. He is being evaluated because of concerns that he suffers from dementia and is presently unable to attend to his basic, daily living needs. The patient denies the presence of mental illness and states, "I don't have an education, no job, no place of my own. I don't have a mental illness." When questioned about a possible head injury he replied that at the age of 7 he was in a car accident and hit his head on the windshield, which according to him has caused him problems with memory.

Throughout the interview his speech was so soft that I had to lean in and request him to repeat his answers. His appearance was appropriate, his attitude casual, his motor activity normal, his mood depressed. His thought content appeared unrelated to delusions or paranoia, and he was not responding to internal stimuli. The sensorium mental grasp showed significantly concrete answers to all questions: To the question "How are a tree and elephant alike?" he replied, "both give you shade"; to the question "How are an apple and orange alike?" he replied, "they have seeds and you peel them." His immediate and recent memory was fair. However, when answering questions regarding remote memory, he would fill in the blanks with tangential rambling or mumble incoherently. When asked to touch his right arm's index finger to his left ear, the patient touched his right ear with his right index finger. To the proverb "A bird in the hand is worth two in the bush" he at first refused to answer and then answered rapidly, "he wouldn't be welcome in my hand all the time, or under the bush all the time . . . ," and at this point he spoke so tangentially and softly that I could not understand the remainder of his answer. His tendency toward tangential speaking appeared to be related to dementia and not psychotic thought processing. He reports that he began drinking alcohol before he was in the sixth grade and continues to drink excessively to this day. However, he does not feel that he has an alcohol abuse problem. The patient states that 10 years prior he attempted to hang himself and admits that he was drinking and very depressed at the time.

Figure 3.9 is his completed assessment. Prior to starting the drawing, the patient stated that he used to be a good artist but now can only draw boxes. Consequently, his house is a three-dimensional drawing of a box. On the bottom he added two windows and the semblance of a door. On the side was an attachment that looks like another window. The house is drawn from a bird's-eye perspective (rejection of the home situation). Its lines are wobbly (organicity, motor control issues) and connect poorly. He next rendered the tree by drawing three lines upward that fall back toward the ground line. He then placed cloudlike outlines on the ends of the tree branches and added a squiggly line for the base with grass growing on either side of the tree. All branches are one-dimensional and connect seg-mentally (organic style of branch development). Writing the name "boy" and then taking the letters and making them into eyes, ear, and head (the

3.9 Organic Brain Syndrome Secondary to Substance Abuse

"b" is the left eye, the "o" is the right eye, and the "y" is the ear, with a quick loop to make the head), he drew his person. He then added the mouth, nose, and a thick neck while reinforcing the eyes. I instructed him to complete the body, and with one line (apprehensive, requiring support and reassurance) he outlined the arms and legs like a gingerbread man. The body leans toward the right of the drawing and is clearly off balance. I asked the patient how he learned to draw a person like that and he proceeded to draw another, this time with a female head, and told me that he had made up the procedure one day and that you can make the girl by writing out "Boy" or "Loyd."

He titled the image "Village" after much contemplation. In addition, he spoke spontaneously about the two people, "The two need to build the house, live in it, and clean it; if they build it, they're a couple living there, keeping it clean.. . ." He then started to talk about the box home and said, "They weren't happy with things I did, they never were satisfied, they couldn't be happy." When questioned on who "they" were he stated, "the children at school."

A structural analysis shows that each item is placed high on the page (anxiety and insecurity in coping with environmental factors) with the home drawn in the uppermost left-hand corner (normal in young children; in adults organic, poor concept maturation). The line quality is heavy throughout the entire drawing (organic quality) with obvious impairment in motor control. The patient's insistence on writing out the word boy in the drawing of a person indicates his reliance on structured patterns to complete tasks.

Overall, the entire rendering takes on the qualities of neurological impairment. According to Buck's scoring system, the patient's IQ fell in the range of 49 with a high of 51. This would place the patient in the mild range of mental retardation, yet, having no premorbid testing available, I was unable to compare his level of functioning. However, the characteristics of his drawing are highly suggestive of organic mental deterioration. If one looks at all three form items, each lacks appropriate motor control, detailing, proportion, and perspective. This organizational difficulty indicates a major organic collapse and perhaps emotional disturbance. Machover (1949) has found that with chronic alcoholics or in conditions of senility "the placement of the figure is relatively high on the page, and often gives the impression that the figure is adrift in space" (p. 90).

Assessing the image from a formal point of reference shows a rejection of the home life, feelings of insignificance, a need for protection, trauma (tree size and branches dropping to bottom of image), and an inability to navigate in his external world.

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