Case Illustrations

As with all case illustrations within this book, the information concerning clinical matters is factual. However, the client's personal information has been replaced to retain confidentality.

Personal Profile 3.1

This case involves a male in midadulthood. When he was a preteen his father died from cancer. He lived with his mother until the age of majority, when he married. Within a few years he divorced and was diagnosed with Bipolar disorder. From this period forward he began to experience hallucinations and paranoia. He stated that he had heard demeaning voices inside his head but that since starting antipsychotic medication he had not reexperienced the auditory hallucinations. However, during this time of stability he assaulted his girlfriend by kicking and punching her and slamming her head against the ground. Additionally, he threatened (with a knife) a stranger in the community who was walking past his house with her children.

Throughout the interview the patient's thought content was grandiose, and he tended to be abrasive in his responses. His attitude was guarded, his appearance neat and clean, his eye contact good, his motor activity normal, his speech at times rapid (he responded in flowery verbiage to both impress and intimidate), his affect congruent, and his mood euphoric. His insight was poor, and he employed intellectualization and minimization. The sensorium mental grasp showed good attention and concentration, an excellent fund of knowledge, and poor judgment and insight. He responded to questions about similarities well if not interestingly. To the question "How are an apple and orange alike?" he replied "fruit." To the question "How are an elephant and a tree alike?" he replied, after a long thought, "organisms." His responses to proverb interpretation ranged from grandiose to mildly paranoid and bizarre. To the prompt "A rolling stone gathers no moss," he stated, "Keep a direction that's healthy; then you won't have to be concerned about things that come from an illness." To the proverb "People who live in glass houses shouldn't throw stones," he replied, "You could be doing something to someone else, but you stand back and make a comment and you may have the same imposition."

Figure 3.3 is his completed assessment.

Prior to the art assessment the patient had emphatically stated that he enjoyed drawing; however, once given the directive he became oppositional. He asked curtly, "a male or female?" When told either would be fine he hur-

Art Therapy Squiggle Drawing
3.3 Bipolar Disorder with Psychotic Features

riedly drew a stick figure (evasion) in the upper left-hand corner. Instructed to draw an entire figure, he drew a female head and called it "Jane." I then gave him the choice of either drawing an entire body or leaving the head suspended in space. He then worked diligently on the drawings.

He drew the female first (possible difficulty in establishing a masculine identity). Both figures are excessively large in size, with the female measuring 10.25 inches in height and the male 11 inches (impulsive, grandiose, possibly aggressive), and the male floats higher on the page than the female (keeps self aloof and relatively inaccessible). Both are drawn with long strokes (requires support and reassurance). The shading is patterned (rationalizes) and geometric. The female was drawn in nine colors and the male in six colors (inability to exercise self-control and restraint over emotional impulses).

Although both heads have overemphasized hair (overthinking, anxiety, fantasy), the female drawing has multiple reinforcements with regard to color and aggressive line quality. The female has tiny half-moon eyes, a squiggly mouth, and bushy eyebrows (uninhibited), with no neck (body drives threaten to overwhelm, regressive). Her face is heavily shaded with yellow (seriously disturbed, poor self-concept). The body is multicolored with an exceptionally heavy trunk (confusion of physical power, maternal symbol), a small waistline, long arms, oversized hands (hostility), tiny sticklike legs with knobby knees or joints (faulty and uncertain sense of body integrity), feet drawn like hands, and a transparency in the feet (pathological aggressiveness) with large clunky shoes that feature aggressive detailing. The client drew squiggles that look like knife slashes on the forearms, thighs, and chest area, as well as the bottom of the dress leading toward the genitalia. Overall the image is menacing, hostile, regressive, and manic in appearance.

I then instructed him to draw a male. He worked quickly on this image and drew the head and face last (disturbance in interpersonal relationships). The image is drawn with angular strokes (masculine), as compared to the first image, which is rounded. The hair is again prolific (virility strivings), the eyes are closed (not wanting to see), the mouth is drawn in a heavy slash like a "V" (verbally aggressive, sadistic personality), and the nose is drawn in the same manner. There is no neck; the trunk is large (unsatisfied drives) and the hands are in proportion, but the left has pointy fingers (aggressive) and the arms are excessively long and thin (weakness and futility). He has drawn pockets on the pants and shirt front (dependency issues, infantile, maternal deprivation). The legs are exceedingly thin, with long feet (striving for virility) and no transparency; the shoes are decorated high-tops (impotence). The "knife slash" squiggles appear on the male also, but not in such proliferation.

He titled this drawing "Bob" and declined to talk about either of the images. The lack of postdrawing inquiry, though unfortunate, does not hinder the interpretation: The clinical interview that preceded the art projec-tive will serve as a guide.

From a structural perspective this patient exhibits not only a sense of grandiosity and egocentricity but poor inner controls and restraint over his impulses. His initial reluctance to complete the task (evident in the stick figure) with concomitant redirecting yielded a hostile response in the drawing of his initial figure (female) with a much less regressive rendering for his male figure. He is overly focused on the past and his own needs for support and reassurance. In addition, the drawings show excessive difficulty in coping with environmental stressors.

From a formal perspective this patient both denigrates women and yearns for a maternal figure that will meet his needs. This infantile dependency takes the form of hostile reactions when he feels deprived or dismissed. His multiple assaults revolve around not only these dependency issues but also his confused sense of manhood, his virility strivings, and power, which is tied into maternal symbols. He feels futile and weak when compared to females and attempts to stave this off through verbal aggression and intellectual defenses. However, when these methods fail, he resorts to physical aggression and sadism.

His history shows that he became excessively hostile after the birth of his first child and was verbally threatening toward a mother and her children. These issues, coupled with his emotional dependence on women and his mental illness, make him pathologically aggressive toward others (especially women) whom he views as thwarting his needs. In addition, significant signs of psychotic decompensation appear in the regressive features, joint emphasis, transparency, unusual coloring, and distorted body parts.

In the final analysis, due to this patient's propensity toward coping with environmental stress with either ambivalence or violence together with psychotic decompensation, the prognosis for this patient is poor.

Personal Profile 3.2

The patient is a single adult male whose father died many years prior to the assessment. When discussing his family, he spoke briefly of the loss of his father and mentioned a younger sister. Of his mother he stated, "She's a basket case like me. She's authoritative . .. but she's also my best friend, but is she ever controlling. I love her, don't get me wrong; she's just a high-strung person." In fact, with each question, regardless of the topic, the patient interspersed every answer with a discussion that revolved around his mother.

The patient was charged with making terrorist threats after having made multiple phone calls to his girlfriend. He has no arrests as a juvenile but many as an adult. Since early adulthood he has been treated for Bipolar disorder, and he describes his illness as follows: "I believe I have a partial mental illness. I do things without thinking, I make bad decisions: . . . I have a Bipolar disorder." As the interview progressed, his mood became increasingly grandiose, and his speech was pressured. He spoke in a rambling manner about his extensive substance use and his prison terms and verified that his relationship with his mother was symbiotic in nature.

His appearance was neat, his attitude was friendly and cooperative, his motor activity was restless, and his affect was mood congruent. The mental status exam showed concrete thinking in response to similarities, with a fair fund of knowledge. His proverb interpretation was expansive and bordered on the bizarre. To the proverb "Even a dragon that walks along the river has small fish biting its tail" he replied, "Even the poor little folks are trying to keep up with the big folks . . . (undecipherable sentence) or vice versa." He denied any suicidal ideation, gestures, or plans, although he did state that he was depressed because of his present circumstances.

Art Therapy Htp
3.4 Bipolar Disorder without Psychotic Features

Figure 3.4 is the completed art assessment.

When administered the DAP assessment, he began immediately and without complaint. He drew both figures on the lower left side of the page (seeks immediate and emotional satisfaction, over-concern with self and past). The male stands five and one-quarter inches high (normal height) while the female stands four and three-quarters inches high (environment experienced as overwhelming). The line type is a long stroke (apprehensive, requiring support and reassurance) with below-average graphic control. Both drawings face forward, with each figure rendered naked but with only the nipples (no genitalia) visible. There is a significant blackening on the male's left hip (anxiety from the waist down) as well as on the male's left hand (preoccupation with that part). In addition, the groin area is crossed over with a double line (conflict relative to that part). On both figures only two colors are used—blue and pink (constricted, emotionally shy).

The patient began by drawing the male figure, which he named Matt. Matt was initially drawn in all blue, and the patient spontaneously stated, "He's a big blue, for boy." The face is round with a triangle nose, simplistic smile, and rounded eyes with pupils. The patient added the features of the head last (disturbance in interpersonal relationships). Once the examinee had added pink, he gave the figure an abundance of hair (anxiety, virility strivings). His shoulders are squared (preoccupied with the perceived need for strength) and misshapen with a shortened neck (uninhibited impulse expression). The long arms are muscular (frequent with adolescents, concerns of masculinity) and end in looped hands with prominent thumbs that point in the wrong direction and toward the reinforced and darkened areas. The trunk is exceptionally thin (frailty, weakness) and has no enclosure (immaturity; regressed, disorganized) with pinpoints for nipples. The trunk extends toward the legs into a block foot (immobility).

The female figure (Jeana) was drawn with the head first (in contrast to the male), an elongated neck (problem with anger management or primitive drives), broad shoulders (confusion of physical power and maternal symbol), and hair excitement or chaos (infantile sexual drives). The trunk has a hint of enclosure (hip line) but again is drawn long and thin. The legs have thin, functional feet. The nipples (infantile nurturance needs) are more pronounced than on the former drawing.

In the patient's story he described Matt as a hardware store manager who fishes with his friends for leisure, whereas Jeana is a cocktail waitress and very social at work. However, at home she reads books and is not social, having few close friends. She gets angry when she has to rush around. Matt becomes angry when he is not being listened to, and he wants to be a productive member of society. The patient finished the story by saying that Matt and Jeana have not yet met but that when they do they may get married.

From a structural perspective the patient, while reserved, exhibits a narcissistic quality, with anxiety and concern focused on the opposite sex and sexual satisfaction. It is difficult to ascertain whether the female is a projection of his mother or his girlfriend, or an amalgamation of the two. However, it seems likely that the female represents the patient's symbiotic relationship with his mother, as this relationship has impinged upon any intimate adultlike instincts. The crossed-out groin also points toward a symbolic feeling of castration.

From a formal aspect the male has an abundance of ideas that point toward frustrated virility strivings and significant conflicts in his personal relationships. In contrast, the female stands on firm footing, yet problems with anger management emerge. In addition, the drawing's representation of reinforced nipples expresses infantile nurturance needs. Once again, whether this is a sign of the patient's needs, the mother's, or a combination of the two is not evident.

In the postdrawing inquiry, the patient verbalized a combination of the structural and formal aspects. Jeana, though displaying appropriate social skills in public, prefers to have only a few close friends and becomes "angry when she has to rush around" (problem with anger management). Matt feels neglected and ignored and desires "to be a productive member of society" (immobility). To complete the story the patient has Jeana and Matt not merely meeting but possibly marrying.

Ultimately, what emerges is the patient's unresolved Oedipal issues and confusion not simply over frustrated sexual desires but also with his anxiety and the attendant fear of castration. Therefore, requiring punishment for his guilty thoughts, he has been symbolically castrated (concerns of masculinity), which is evidenced in his reinforcement and shading on the male figure from the palm of the hand to the crossed-out genitalia. In addition, this narcissism has not found outward expression, and he has found himself overwhelmingly frustrated when seeking mature sexual relationships and adult responsibilities. Overall, psychotic processing difficulties were not evident; instead, infantile nurturance needs emerged.

The prognosis for this patient at the present time is good if he can receive individual counseling, group therapy, independent living skills training, and anger management or stress management classes. However, a return to his maternal home, instead of placement in the community at an adult group home, is not recommended—for obvious reasons.

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