Case Illustrations

The following profiles illustrate the use of the 8CRT in specific situations.

Personal Profile 3.5

The client is a teenaged male in therapy due to extensive drug use with a series of juvenile arrests and probation violations. His parents are presently separated, but both are appropriately involved in his treatment. Throughout the initial interview, the client presented with an elevated and grandiose mood, an animated affect—especially when recalling his probation violations—glorification of past substance abuse, and frequent testing of limits with a mixture of flippant and apathetic responses. His single goal is to improve his communication with his mother.

The client showed appropriate attention and concentration, with a good fund of knowledge. His responses to similarities were concrete and showed a lack of abstract ability. To the similarity "How are an apple and orange alike?" he replied, "because they're big." To "How are a chair and table alike?" he stated, "because they're made of wood . . . no, wait, because they fit together." To the proverb "A rolling stone gathers no moss" he replied, "rolling stone going through grass or something." It should be noted that these vague responses may be a function of his lack of effort toward the task rather than one of inability.

Figure 3.10 is his completed art assessment.

Page 1 of Figure 3.10 is drawn over eight inches high (self overemphasis and environment underemphasis; impulsive, possibly aggressive) with an abundance of hair (virility, masculine symbols) and a prominent mullet. He is wearing sunglasses (guarded) and has a detailed ear, heavy beard growth, large jagged teeth (aggressiveness), muscular bicep, and tiny forearm. His fingers are pointed (aggressive). His jeans are detailed with two pockets (maternal issues), and his shoes are also detailed with laces, while his left foot rests on a box of sorts. He is drawn in profile view (avoidance of the environment).

Page 2 is superimposed over page 1, but the right foot is missing and the jeans are drawn with a heavier line. The figure has a stump for an arm (helplessness), a prominent eye (hypervigilant), and heavily shaded hair (anxiety, overthinking), and instead of a nose he now has a bird beak (phallic drives). The drawing remains large (grandiosity, poorly developed inner controls).

Prior to drawing page 3, the client was redirected to draw a person, not a hybrid. This figure has the same body superimposed, with the right foot

Slash Line Mouth Draw Person
3.10 Conduct Disorder, Adolescent Onset, Severe
Rskola Nslor
3.10 (continued)

now added. The stump of the arm remains, and a belt is now present. This figure has a prominent chin (need for social dominance), with a small beard on the chin edge, and a bulbous nose with nostrils (aggression) replaces the beak.

By page 4 the same instructions were given, but without the tonal emphasis on "person." This image is now an amorphous ghost overlapping page 3 (interaction is detached, denial). The snakelike ghost has a skull for a face, one nostril (aggression), aggressive teeth, large ear (sensitive to criticism), clawlike hands, and a large knife extending from the index finger on the figure's left hand.

Page 5 is yet another overlap (avoidance and running away from problems/interpersonal relationships). The Dali-esque figure has an extremely large, profiled head (focus on self, preoccupation with fantasy, grandiosity), decorated like a warrior with a topknot for hair, goatee and mustache, long sideburn, quizzical eyebrow (masculine symbols, virility strivings), and a single horn on the forehead. The body is tiny with sticklike fingers (aggression).

Page 6 ignores the directive almost entirely and is yet a third in the series of overlaps (extreme denial). The drawing has a naked human body with the head of a cat (detachment, self-centeredness, feminine symbol). The figure takes up three quarters of the page, and it is squatting, with a singular belly button (maternal dependence, infantile needs) as the only body detail.

Page 7's overlap shows a significant size decrease with the body of a teddy bear (infantile needs) and a skull head or human face, which appears berating. Again aggressive teeth are prominent; one eye is significantly larger than the other, a nostril is drawn in heavily, and there is anxious shading under each of the eyes.

In page 8 the figure is seated (dependency, inhibited energy, lack of drive) in profile and is similar to page 1. The person has a prominent head of hair (virility) and a goatee; the eye is looking at the viewer, and the right arm has an extremely large index finger (pointing toward the ground), which is reminiscent of an oversized middle finger (oppositional; hostility). The figure has a huge belly that extends beyond the shirt with a prominent belly button (nurturance, dependency needs). The midline is stressed (emotional immaturity, mother dependency) and the legs are long and thin.

In the final analysis this client is initially highly defended and tends to approach life situations in this manner. Yet, left unchecked, he will quickly return to dependency and nurturance needs (pages 6, 7, and 8). However, it is important to note how he attains control. By page 2 the client began to show his oppositional traits in order to engage the therapist in a manner that required redirection. When this was provided (external control), his image returned to human form (page 3). However, by page 4 only the directive was offered, and the client continued to draw nonhuman figures until the final one at page 8.

This indicated that he does have internal control but relies heavily upon authority figures to guide and caretake. In addition, this client is sensitive to criticism, yet he seeks out verbal reprimands, which causes me to wonder if that is his only mode of interaction with his family and subsequently the environment. Furthermore, his projected aggressiveness, coupled with his dependency needs, appears to be focused on the parental dyad and related to his conflictual feelings of infantile dependency and his need to exhibit virility with a frustrated adolescent's mind-set (i.e., grandiosity, poorly developed inner controls, recognition through antisocial activities).

That his drawing went from a cloaked (sunglasses) and belligerent person to a seated and defeated male shows the patient's grandiosity toward masculinity, yet feelings of inferiority cannot be held at bay and therefore become prominent in his drawings as the layers of personality are stripped away. Unfortunately, his hostile pride does not allow the affect, and he therefore denies these desires by avoiding emotional attachments and shuts out the overwhelming feelings through antagonism, substance abuse, antisocial relationships, and ultimately the defense of reaction formation.

It will be imperative that future sessions concentrate on increasing decision-making ability and autonomy. Helping professionals and family members will have to make a conscious effort not to enter into a codepen-dent relationship and must therefore provide consistent structure and consequences for choices of behavior, setting realistic goals for his future, becoming involved in peer interventions and group therapy, and in due course exploring his grandiosity as overcompensation for feelings of dependency.

PersonalProfile 3.6

The final 8CRT assessment we will review is based on two projective tests given to the same client. The first examination is called "Draw-a-Person in the Rain" (Figure 3.11), which is loosely based on the DAP pro-jective test and measures an individual's ability to deal with stress from the environment. The second test (Figure 3.12) was the 8CRT and was administered over 1 year later. This test was utilized to assess the patient's functioning with regard to stabilization as the treatment team looked toward community placement.

Schizophrenic Draw Person
3.11 Draw-a-Person in the Rain

The patient is a middle-aged male, who had molested his latency-aged daughter. When questioned as to why he did so the patient replied, "she never called me Daddy, and I wanted her to know she came from my bloodline. ... I was drinking. ... I feel sorry I did it." He has a long history of hallucinations and delusions and has stated, "I thought I was Jesus; my mother called the paramedics." Throughout the interview, the patient's speech was coherent but at times disorganized, with mild thought blocking evident. His motor activity was normal, his attitude cooperative, his appearance appropriate, his eye contact good, and his affect congruent to the topics discussed. He showed no overt signs of hallucinations or delusions but did have mild disorganized and tangential speech. His insight was fair. His proverb interpretations ranged from bizarre to concrete. To the proverb "A bird in the hand is worth two in the bush" he replied, "gonna make an egg"; to "People who live in glass houses shouldn't throw stones" he replied, "because it will shatter."

Art Disorganized Schitzophenia
3.12 Schizophrenia, Paranoid Type
Caligor 8crt
3.12 (continued)

A review of the client's body of work from art therapy groups together with his verbal statements and delusional subsystem showed a symbolic abundance of ideas focused on his father, on his being recognized as a father, and on God (the "universal" father) and the Bible. Looking at this client's abundance of ideas from a psychoanalytical point of view Gay citing Freud (1989) states, "that his personal relation to God depends on his relation to his father in the flesh . . . and that at bottom God is nothing other than an exalted father" (p. 504). And it is this parental engulfment that had become incorporated into the client's psychotic processing, resulting in a regressive fixation that was both delusional and incestuously pedophilic.

In Figure 3.11 the patient drew the reinforced clouds and long rain splatters first. It is important to note that the rain is not merely falling but also splashing upwards once it hits the ground. The oversized head shows a preoccupation with fantasy life (focus on mental life), the tightened legs indicate sexual maladjustment, and the overemphasized nose suggests phallic preoccupation. His closed eyes indicate his self-absorption, while his outstretched arms provide a feeling of strength and power. Yet it is only the lower half of the body that is reinforced and detailed. The patient stated, "the man was standing in the rain with his shirt off; he's happy because it hasn't rained for 40 days and 40 nights."

In short, the image suggests sexual difficulties, fantasy preoccupation, hostility hidden behind a powerful persona (possibly a reaction formation), and a storm that not only falls from above but also surrounds the person with external pressures. The patient's verbal statements indicate his religious preoccupation.

One year later the client was administered the 8CRT (Figure 3.12) as a continuing assessment of his functioning. He entered the testing session apprehensive and mildly paranoid about how the results of this test would be utilized, so I informed him that this was a follow-up to earlier testing (Figure 3.11) and would be used to determine the degree of his stabilization.

Page 1 shows an extreme presence of "Spiderman" squatting. The figure has hollow eyes, emphasis on the chest area (muscles), small rounded fingers, and no feet. In addition, in the genital area of the figure are two heavily shaded testicle-appearing shapes with a straight line that runs from the midsection to the base of the "testicles" and gives the impression of being a vagina.

Page 2 also shows extreme presence. It depicts a woman with a rounded head and a bobbed haircut that does not touch the head, appearing to hover. The nose is prominent, and the mouth has large cupid's-bow lips. A tiny neck connects to broad shoulders. The biceps are muscular; the fore arms are tiny, and the hands have splayed fingers. The waist is cinched with a belt; there are no hips. The figure wears a long skirt, boots, and a pearl necklace. There is emphasis on the chest area that does not look like breasts but like male pectorals. The overall figure is drawn in the same schema as the patient's male figures but with female endowments (skirt, necklace, and bobbed hair).

The child figure on page 3, the first regression, is placed at the bottom center of the page and leans precariously toward the right side. The drawing is below average in presence and tiny in comparison to the first two. It is drawn in profile, and the patient stated, "I used to draw this when I was seven." The male figure has an Afro, an emphasized ear (sensitive to criticism; hallucinations), and a line slash for a mouth (tension, shutting the mouth against something). His chest is overly large (virility strivings), and there is a hump on the back of the figure. A pocket (dependency issues) adorns the shirt, and his right arm extends into the pant pocket (evasiveness), with a belt at midline (dependency issues). His leg is short (immobility), and the drawing only indicates one leg (unbalanced).

Page 4 depicts a female child who is placed in the center of the paper and has wiggly lines for hair, empty eyes (hallucinations, desire to see as little as possible), an emphasized nose, and cupid's-bow lips (sexualized). Her hands are on her hips; her trunk is short with a cinched waist. She is wearing a skirt and has two sticklike legs with rounded balls for feet. Due to the hair excitement (infantile sexual drives) and hollowed eyes, she appears to be scowling.

Page 5 is yet another child, but at this juncture the client has reverted to drawing cartoon characters. This is a drawing of Charlie Brown on his pitcher's mound. He is drawn in profile with a large chest and squared trunk that give him the appearance of having a hump on his back. His hat is worn backwards, and he has an ear, an empty eye, and a line slash for a mouth. His arms extend out from either side of the trunk, and one hand has a mitt, while the other is holding a baseball. He has a belt, and again the drawing indicates only one leg. This figure resembles page 3 in many ways (the drawing style, appearance, and symbolism) and is interpreted in that manner.

Page 6 continues with the cartoon character theme with a drawing of the Incredible Hulk. This figure has an extreme presence and takes on an aggressive tone of uncontrolled rage or lust. He has an aggressive face with squared head, large staring eyes, circular mouth, and teeth (aggressiveness). He is overly muscular, with pectorals, and has a belly button (maternal dependency issues). His feet are oversized, as are his hands, which are large closed loops (desire to suppress aggressive impulses).

The client identified page 7 as Supergirl. She has outlined hair, empty eyes, and a cupid's-bow mouth. Her arms are indistinct, and she has no hands. Her legs are thin, and she is wearing boots. A cape with a large "S" logo flies out from her left-hand side. At her midsection is a shape that looks like pantaloons or a diaper. The patient commented, "I like superheroes."

At this point the patient had drawn many superheroes, and I requested that he draw a real person, rather than a cartoon figure, for page 8. The large head (delusional; fantasy life) is rounded, with no hair (lack of virility) and an oversized forehead. The patient drew a moustache and beard (phallic substitutes) and stated, "I wish I could grow a better beard." The figure has large, prominent eyes (paranoia, watching all the comings and goings), nose, and cupid's-bow lips with a profusion of teeth visible (aggressiveness). His ears are emphasized (sensitive to criticism; auditory hallucinations). His neck is short and thick, and he has broad shoulders, a muscular chest, a belly button (dependency), strong forearms, a cinched-in waist, and a detailed belt (maternal dependency). His legs are drawn together (sexual maladjustment) with toes pointing in the opposite direction (ambivalence). His left arm is waving in the air, while his right is squared and toward his side.

From a quantitative standpoint, the figures present with two polarities: adult figures with extreme presence (pages 1, 2, 6, and 8), and figures of average height that are regressions to childhood (pages 3, 4, 5, and 7). This polarity presents us with an adult who exhibits an immature self-concept while reflecting discomfort with his adult role. He experiences the environment as demanding and reacts with impulsivity and excessive fantasy. Additionally, each figure shows a continuity that is overlapped.

From a quantitative analysis, this level of detachment is unusual, as most subjects are unable to sustain the emotional distancing and tension that overlapping requires (Caligor, 1957). Due to this detachment, if we were to look at each rendering placed one atop the other, they appear a haphazard lot. However, if qualitatively we look at the renderings and take them into account as one would a story or book, the patient appears to be communicating his sexual confusion, dependency issues, fantasy preoccupation, regressive tendencies, and fears that his anger and passion will engulf his identity.

Thus, page 1 is the superhero Spiderman, who is virile, capable, honest, and dependable. In addition, this figure is endowed with testicles but also confused sexually as he has a line representative of female genitalia. This confusion from the patient is symbolic of his own internal uncertainty surrounding virility/manliness and shame, which point us toward Oedipal issues in page 2. The only adultlike female figure is overlapped and found standing on the genitalia of page 1, while page 3 is an unbalanced drawing that the patient stated he used to draw as a young child (the same age as his victim), and this image culminates in page 4, where the female child appears scolding. Page 5 is a facsimile of Charlie Brown, a symbol of all that is inadequate, insecure, and fearful within the child. As we move into page 6, the preceding drawings are now overcome by the uncontrolled rage (lust) of the Incredible Hulk.

One may recall that the Hulk story is based upon the premise of a mentally ill (multiple personality disordered) male who turns into a "monster" when angered. The desire to repress and deny the hostile impulses is unfortunately overrun by anger and inner desires. We can view this symbolism as a projection of the patient's own feelings of lust and uncontrolled passion. Page 7 continues the theme of superheroes and shows Supergirl. A companion to Superman, she possesses the same powers, yet the patient has infantilized her in diaperlike pantaloons without hands with which she could repel or maneuver. In addition, the patient returns to fantasy preoccupation and comments on this by stating, "I like superheroes." By page 8 I had prompted the client to draw a person rather than a superhero (compare the similarities in Page 6, Incredible Hulk, and this figure). This drawing again indicates the struggle for opposites within the patient, with an overwhelming sense of dependency and neediness offset by a vision of sexuality and virility (the patient stated that he wishes he could grow a better beard).

Overall, it appears this patient's psychosis is mainly stabilized through his medication regime; however, it remains an activating force. The drawings when taken as a whole symbolize the forbidden sexual desire (mother figure) that leads this patient to renounce adult females, focusing instead on an immature sexual fixation and delusional material that when circumscribed produces humiliation and guilt. These feelings lead him to self-reproach, which heightens his feelings of guilt and shame and thus brings on stress that could result in a psychotic decompensation, especially if his defense mechanism of incorporation remains strong. This patient is infantile in his thinking, and the combination of his extreme dependency issues and his need for virility and regard from without is a lethal combination. This patient's struggle with opposites has left him in a precarious position that threatens to overwhelm his weak sense of self.

On the whole the client does well with the structure and safety of institutionalized living, where schedules are set and orderly. It is the community issues that he must tackle with their myriad difficulties, frustrations, and disappointments. Therefore, this patient needs to increase his indepen dent living and real life skills by learning to cope with situations that will in some form replicate life traumas while he remains in a safe environment. It is also imperative that he receive one-to-one individual therapy that explores his struggles (e.g., Eriksonian work with personality and psychosocial development) to help the patient progress from an infantile manner of relating to one that is autonomous and healthy. However, this patient has a delusional makeup that may preclude any further work, because his fixation in infancy/dependency, coupled with the defense mechanism of incorporation, fuels his delusional thought processing. Yet, in the words of Erikson (1963),

In psychopathology the absence of basic trust can best be studied in infantile schizophrenia, while lifelong underlying weakness of such trust is apparent in adult personalities in whom withdrawal into schizoid and depressive states is habitual. The re-establishment of a state of trust has been found to be the basic requirement for therapy in these cases. For no matter what conditions may have caused a psychotic break, the bizarreness and withdrawal in the behavior of many very sick individuals hides an attempt to recover social mutuality by a testing of the borderlines between senses and physical reality, between words and social meanings. (p. 248)

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