The client is a single young adult male. Records indicate that his parents were divorced when he was a toddler, and he has focused his anger on his mother. She states that while in preschool he threw a burning stick at her and was later found standing over her with a pair of scissors. These episodes never resulted in any physical injuries but would end in screaming matches. From this time forward he lived with his father, who physically abused him on numerous occasions. He has been incarcerated since late adolescence, and he attempted suicide while in prison. The patient has also spoken of sexual incidents that occurred during his incarceration, many of which were consensual in nature. He reports a history of visual and auditory hallucinations that have convinced him that demons are after him. He states that in the past he saw demons, a bright light came through his bedroom door, and two shadows of demons paralyzed and levitated him. He further reports that he has felt an "evil wind blowing through my soul." Presently, he believes he has a mental illness, but he is hard pressed to describe or identify the illness. Instead he states, "I worry, I'm confused. . . . It's a lack of faith." He states that he has not had any delusional thoughts for some time, but he doesn't believe that his medication is the cause; instead he believes it is because he "reads the Bible, has faith, and prays."
Throughout the interview he was cooperative, with normal motor activity. His speech was soft but coherent, his appearance neat. His mood was depressed; he made self-deprecating remarks, and his thoughts were preoccupied with religion. His insight was fair to poor. He was able to answer similarities without problem, and his fund of knowledge was excellent. His response to proverb interpretation was appropriately abstract. To "even a dragon that walks along the river has little fish biting its tail" he replied that the proverb said "that we're all made alike." The patient has an extensive substance abuse history. In his early adulthood a screening measure used to identify persons fabricating psychological and physical symptoms found that he had a tendency to exaggerate symptoms, and the patient gets secondary gains from his delusions. He has often stated, "I know I'm the Antichrist."
In early adulthood the Culture Fair Intelligence Test measured his full-scale IQ at 77; however, by late adulthood he was retested using the WISC-III and garnered a full-scale IQ of 85.
I gave the client the HTP art projective test based on John Buck's original design. Panel A of Figure 3.5 shows his three drawing items. Following the analysis (as recommended by Buck), panel B of Figure 3.5 will illustrate the second and most frequently employed method of HTP assessment to compare and contrast the two techniques.
Qualitative Analysis: Details (Figure 3.5A)
House: (1) There is no chimney (lack of warmth in the home situation, lack of psychological warmth, or difficulty dealing with a masculine sex symbol); (2) the house lacks a bottom wall baseline (poor reality contact); (3) the door floats above the implied wall baseline (interpersonal inaccessibility).
Tree: (1) The trunk of the tree was completed first in a clearly phallic shape (feeling of basic power and ego strength); (2) the client placed special emphasis on the apples and branches through erasures (anxiety, dependency, and oral needs); (3) the branches are one-dimensional (patho-formic) and drop toward the bottom of the picture (trauma with regard to contact in the environment); (4) the amount of detailing for the tree is in direct contrast to the detailing for the house and person.
Person: (1) The hair was drawn first, erased, and then emphasized (virility striving, freedom); (2) the shoulders are large and excessively squared (defended, preoccupied with need for strength); (3) the neck is nonexistent (body drives threaten to overwhelm); (4) the person is clothed in a trench coat (security and protection, defensiveness).
Qualitative Analysis: Proportion
House: The door is drawn excessively large (dependent).
Tree: (1) The tree is small compared to the form page (feelings of inferiority, insignificance); (2) the branches of the tree dwarf the size of the trunk (inadequacy coupled with striving for security and satisfaction within the environment).
Person: The person is small compared to the form page (feelings of inferiority, insignificance).
Qualitative Analysis: Perspective
Tree: (1) The tree is placed high on the page and toward the left corner (seeks satisfaction in fantasy, aloof, insecurity with environmental factors); (2) it leans definitely toward the left (seeks immediate and emotional satisfaction, overconcern with self and past).
Person: (1) The person is placed in the exact position of the tree (seeks satisfaction in fantasy, aloof; insecurity with environmental factors); (2) the person has a slight lean toward the left (attempts to suppress the future with preference to the past).
Qualitative Analysis: Time
House: (1) After completing the garage door and prior to beginning the upper story windows, the patient ceased drawing for many moments and spontaneously stated, "It's hard to tell people about what bothers me I have to look at people and then I forget it's hard to get across. I worry about things ... all this little paranoia" (feelings of alienation regarding home and family); (2) after completing the upstairs window (which he identified in the postdrawing inquiry as his room) he spontaneously asked, "Do you think there's anything wrong in being religious? I don't think there is. I think there's a time and destiny for everyone" (found solace and acceptance in religion through the escape/withdrawal of his bedroom).
Qualitative Analysis: Comments, Drawing Phase
Tree: (1) After erasing and adding a second berry to the bottom right row of branches, he made a superfluous comment: "It's a little bit detailed" (insecurity); (2) he then immediately made a series of unrelated comments ("I stay up late at night chewing tobacco or reading a book"), and at this point his speech became so rapid that I could ascertain only his general topics. These comments focused on his medication, his drug use (present and past), and confrontations by peers in his dorm. After this comment, he then added the rounded top to the trunk of the tree (regression as the tree took on a more phallic form).
Person: (1) After completing the person's hair he stated, "This was old-style long hair. I never grew my hair long" (virility strivings); (2) after completing the trench coat he stated, "I was thinking, I know it looks like a warlock or something" (constant struggle between good and evil, God and devil, superego and id).
Qualitative Analysis: Comments, Postdrawing Inquiry
House: (1) The house is above the client, and while he was drawing it it reminded him of his mother's house (personal relationships regarding home and family; feels insecure, insignificant); (2) he stated that it was a friendly house but then added, "I wish I had better memories of being there, but when I was there, I was mentally ill" (contradicts statement of happy memories with unpleasant experiences); (3) he added that what the house needed most was "to be taken care of. . . . You have to fix it" (patient needs to be taken care of, fixed).
Tree: (1) The patient stated that the tree was feminine because "with her caring heart she shows her fruit," which was determined by "lots of nice apples" (sexual and maternal symbols combined); (2) the tree reminded him of "how a person should grow up and produce good fruit" (concern and obsession with his mental illness as a "defect," with resulting religious metaphor relating to fruit of her womb; sexual, maternal, and religious symbols combined).
Person: (1) The male's name is "Werewolf," and the patient is attempting to convert him to Christianity by "talking about the Lord," but Werewolf is thinking about "how good a feeling hard rock music gives him" (religious delusional thoughts surrounding struggle to remain pious; good and evil thoughts comingling); (2) the person is "sick in the mind" because "he won't stop using drugs and he's into witchcraft" (projection of patient's internal struggle); (3) unlike in the drawings of the house and tree, the weather in this rendering is "cold and rainy. A light drizzle" (depression, external pressures); (4) in response to the question "what does this person need the most?" he said, "support and love from a higher power" (retreat into delusional or religious belief system for dynamic needs).
Qualitative Analysis: Concepts
House: His house should be built on a ranch, which is a frequent topic of this patient (i.e., living on a ranch, being a "cowboy"; desire to retreat to open spaces, anonymity through a masculine and "tough" symbol).
Tree: The tree is a healthy apple tree because "you don't see hardly any dead spots" (infantile dependency and oral needs ill disguised).
Person: The person is a werewolf (sexually predatory symbol) who prefers drugs and witchcraft to religion and conventionality (powers that threaten to emerge from within the patient).
Quantitative Analysis: Summary
According to Buck's scoring system the patient's raw G IQ is 73 and his net weighted score IQ is 77, which places the patient in the Borderline Intellectual Functioning range. His good IQ score correlates to an IQ of 83 and represents his ability to interact in his environment. However, his interests are relatively simple and material in nature. An overview of his detail, proportion, and perspective scores basically yields difficulty surrounding critical and analytical judgment regarding the more basic problems that are presented by the environment. The patient's lowest overall scores appear in the drawing of the tree, where individuals generally attain their highest score. This expresses significant conflict in the patient's basic feeling of ego strength.
Evaluation of his HTP reveals the presence of the following characteristics: (1) feelings of insecurity and inferiority regarding masculinity, resulting in an attendant withdrawal into masculine symbols of power; (2) infantile and orally dependent traits that cause sexual symbols and maternal symbols to be united, creating possible Oedipal conflicts; (3) a tendency to retreat into a delusional or religious belief system to meet his dynamic needs when body drives threaten to overwhelm.
In the end, this patient is essentially immature, with infantile dependency needs and predominant feelings of shame and humiliation that impede his general functioning within the environment. He therefore seeks a sense of superego through religious preoccupation. Yet, in the fantasy of finding himself through his delusional belief system, he instead loses himself.
The same patient also took a shortened version of the HTP art projective test (panel B of Figure 3.5). He began this drawing with meticulous lines that are minimally wavy in appearance but otherwise well drawn. The house is completed in one color (constricted use), the tree in two (brown and green), and the person is outlined in a pale yellow with brown belt, hair, and feet (constricted use). All items are placed one third of the way up the page, with the person to the furthest left (seeks immediate emotional satisfaction; concern with self and past), then the tree, and then the house. There is no ground line under any of the renderings.
The house has three outlined roofs, which makes it look like a Tudor style. It has a large, rounded doorway (overly dependent) with a multiplicity of windows. Each window has a centerline designating the pane of glass. The house, though drawn well, appears impersonal and daunting.
The tree is to the left of the house and has a long trunk (feels constricted by and in the environment) with three branches on either side and one on top. It is very symmetrical in appearance (ambivalence regarding course of action). The leaves are carefully drawn as circles emanating from the branches (clinging to nurturance, dependency issues), again very symmetrical. There is no ground line delineating the base of the trunk (vulnerable to stress).
The person was drawn last and is outlined in yellow so that the body is almost invisible. The client began by drawing the feet first and ended with the head (disturbance in interpersonal relationships, possible thought disorder). The arms are raised in a gesture of hopelessness or a bodybuilding pose. While drawing the arms the client stated, "I didn't draw the arms very big" (critical comment regarding power and strength). There is no face indicated (poor interpersonal skills, withdrawal), only hair (expression of virility striving; masculinity and strength), which is drawn with quick bursts (infantile sexual drives), a midline belt on an otherwise naked figure (emotional immaturity, mother dependency, feelings of inadequacy, sexual issues), and frantically drawn large balled feet (striving for security and virility). The figure has one hand (the right) with fingers indicated, while the left hand is merely a pointed line (guilt, insecurity, difficulty dealing with the environment). The figure's legs are long in comparison with his torso (striving for autonomy). When I asked him if he wanted to add anything, the client added windows to the bottom story of the home, including two beside the arched door. He titled the drawing "Eastern U.S. Home."
He told the following story: "He's happy. This room [pointing to window beside the door on right] is the kitchen [oral needs, need for affection]. This room [pointing to window beside door on left] is a bathroom [elimination]. Behind this is a living room and family room [social intercourse]. This room [pointing to upper story, center windows] is one large room. His room is that room. He lives in the house alone. ... He built it with the hopes of finding a wife and having two kids (a son and daughter). . .. He's 34 years old and the house is on ten acres."
Overall, the patient's completed drawing indicates feelings of constriction within the environment, a concern with the past, and marked disturbances in interpersonal relationships (dependency, helplessness) coupled with a desire for intimacy. His spontaneous comment regarding the drawn figure's lack of strength and power is in proportion to the symbolic abundance of ideas that focus on emotional immaturity, dependency issues, insecurity, and infantile sexual needs. The patient generally feels insignificant and inadequate. Even though the tree is drawn well, the figure shows that in the environment the client desires virility and security, yet the figure's yellowed outline bespeaks of emotional and physical withdrawal. The absolute symmetry that he applied to the tree (and home) also points in the direction of the patient's ambivalence toward intellectual or emotional satisfaction. Therefore, unable to decide, he withdraws into the comfort of an oversized and impersonal world (institutions, religion, fantasy) where his basic living and dependency needs are provided. The drawing does not indicate overt psychotic thought processing, and it would appear that the patient's medication regime has circumscribed his delusional subsystem. He does, however, exhibit a high degree of depressive features in concert with dependency issues.
When we compare the two panels of Figure 3.5 from a qualitative perspective, the information we glean about the two HTP assessments is remarkably similar. In both instances we see feelings of insecurity and infantile sexual needs. However, Buck's original design produced a richer picture of this client's internal struggles. Although his delusional retreat was evident in the adapted HTP, it was in no way as detailed with regard to internal processing difficulties, especially those related to his mother in concert with his body drives. The postdrawing inquiry consequently allowed a closer scrutiny, which permits the clinician to apply a wide range of theoretical constructs to the therapeutic hour.
Thus, if we were to provide treatment for this institutionalized client, Table 2.3 offers three distinct stage theories of development, and one can see how the client is fixated within the Piagetian stage of formal operation, the Freudian genital stage, and the Eriksonian phase of identity versus role confusion, and any of these theories offers an appropriate starting point for the treatment plan.
As we move into a comparison of the two HTPs from a quantitative examination, the raw G IQ score and the good IQ score remained relatively the same (73/83 on the original and 74/80 on the adapted test). The tests differ in the net weighted score IQ (points toward the client's potential level of functioning), with 10 less IQ points measured on the adapted projective test. Taken as a whole, both tests pointed toward Borderline Intellectual Functioning, while the WISC-III score of 85 placed this patient in the low average range.
Yet the testing that was administered when the patient was in early adulthood should not be overlooked. The Culture Fair Intelligence Test, an instrument that measures intelligence that is not influenced by cultural background or scholastic training, produced an IQ of 77. In comparison, the IQs from both HTPs are within mere points of each other, which may be due to the fact that both the HTP and the Culture Fair Intelligence test rely little on verbal training; as Craddick (1980) has stated, "Projective tests (such as the Rorschach) are by their very structure more likely to elicit pathological responses than will the WAIS [Wechsler Adult Intelligence Scale], for example" (p. 914).
Although this client was able to fully participate in a battery of verbal testing treatment, a clinician's work with the difficult client often requires a broad knowledge of diverse cultures. These diversities are not relegated only to cultural traditions, religion, and generational differences, but also encompass clothing and food preferences, communication styles, morality, control of aggressiveness, and socioeconomic differences. Consequently, cultural variations affect patterns of communicating, behaving, understanding, and problem solving. However, as related to art therapy, research has indicated that "children up to age five, regardless of cultural or ethnic origins, follow a specific pattern. . . . These [patterns] in turn become the basis for recognizable images . . ." (Levick, 1983, p. 45). If you review Table 3.1 you will notice a guide to normative stages in children's art. This guide was taken in part from Lowenfeld and Brittain's (1982) research on childhood developmental stages, yet a quick search of their index for cultural issues finds them linked only with aesthetics. There is no mention of how culture affects art development and no discussion of any cross-cultural commonalities that may exist within childhood renderings.
To address this deficiency in the research Alter-Muri (2002) began "an informal inquiry into how Lowenfeld's theories might function today" in which "one hundred and fifty-six drawings by children ages 3 to 11 from schools in Switzerland, Denmark, Germany, France, and Hungary were collected" (p. 178). Just as childhood developmental stages (art) paralleled Piaget's cognitive theories (see Chapter 2), the results of Alter-Muri's study found that Lowenfeld's methods were applicable across cultures in Europe. Unfortunately, the research inherent in a qualitative breakdown of a projective test is often based upon Western criteria. For that reason, when taking cultural variations into account "projective techniques are found useful when the researcher is investigating a specific hypothesis, using an objective system of scoring" (Al-Issa, 1970, p. 495).
Figure 3.6 provides an example of the use of HTP with a patient from a different culture: in this case, a male from India who spoke rudimentary
English and required specialized interpreters, as his village dialect was obscure. I chose the HTP projective test for its previously noted ability to measure independently quantitative details and for its objective scoring system. However, I must state that Buck's study (not unlike Lowenfeld's) focuses on research developed by Western participants and standards. As Machover (1949) has observed, however, common social meanings are inherent in artwork, especially in human figure drawing, and facial characteristics transcend variations in culture or in drawing skill. Thus, the human figure should contain (with exception made only for consequences of figure positioning or an absence accounted for verbally) a head; a trunk; two legs, arms, and eyes; a nose; a mouth; and two ears (Buck, 1966). Additionally, Figure 3.6 contains two drawings completed within two months of one another. The HTP on the left was completed without an interpreter present and therefore was not accompanied by a postdrawing inquiry, while the session that produced the drawing on the right utilized an interpreter. I performed the projective test twice to see if the client's drawings would differ after the client had settled into the milieu of institutionalized living. As you will note, they differ very little, with the exception of the form page's having been turned vertically for the initial drawing. However, the second rendering shows two significant differences: the omission of the mouth and the presence of a seemingly barred door. These differences could be attributed to the patient's inability to communicate in his natural language (the absence of the mouth) and his separation from his family and culture (the barred door, which may also imitate the locked and impersonal institution in which he now resided). For purposes of this discussion I will be interpreting the second rendering (as this was accompanied by a brief postdrawing inquiry), and I have administered the test based on the shortened version of Buck's design.
The client is a married adult male. He immigrated to the United States with his wife when he was in his late 20s. He is the oldest child in a middle-class family. He stated that he prefers living in the United States, "because of the opportunities here." The client was being interviewed due to his unprovoked assault on a coworker. Apparently, family difficulties had created a situation in which he was sleeping poorly and had stopped taking his prescription medication. On the day of the assault others had noticed he was acting bizarrely, and his supervisor had offered to send him home. However, he declined the offer, as his family needed the income from his job. When questioned about his mental illness he stated, "I have a weight on my brain. My doctor [in India] said I imagine things in my brain." Although he denied hallucinations or delusions, he did admit that historically he had heard voices. Throughout the interview the patient's attitude was pleasant and cooperative, his motor activity slow, his speech soft, and his appearance disheveled. His responses to similarities (a measure of general intelligence) were appropriately abstract. His affect and mood were depressed. He showed no signs of thought disorder or delusional content. He denied a substance abuse history and admitted to depressive tendencies when he heard voices. He stated that he had completed the 10th grade in India, a level of education that the interpreter characterized as being equivalent to a high school education in this country with some college. The diagnostic impression was Major Depressive Disorder with Psychotic Features.
Prior to reviewing the art therapy assessment, it is important for us to discuss some issues related to cultural considerations. The first revolves around the dedication to family and community inherent in the region from which this patient came. Morris Opler (1959) explored a village in India and found that the beliefs and customs of the villagers were characteristic of the region. Although Western influences have penetrated the area, many traditions and festivals continue to be observed. In fact, these villagewide rites are integral not only to culture but to the family as well; 25 of 40 rites "revolve around family needs and purposes" (p. 288). One such traditional celebration is called Divali (festival of lights): As recently as 1959, this ritual found a villager entering homes where the owner had gone to sleep and "calling loudly for the Goddess of poverty to leave the home and for a God or Goddess of wealth to enter" (p. 281).
Furthermore, the caste system, while no longer sanctioned, is a long-established classification in India. This system organizes the social classes in the following order: (1) Brahmins—priests; (2) Kshatriyas—royals, rulers, or warriors; (3) Vaisyas—merchants, farmers, or professionals; (4) Su-dras—workers; and (5) Pariahs or Harijans—beggars or the diseased (Kipfer, 1997). Under this system the client's family and personal doctor would fall within the Vaisyas. With regard to cultural influences on depressive symptomatology, Wittkower and Rin (1965) tested Cohen's (1961) hypothesis that "psychotic-depression [sic] is generally more frequent among those persons who are more cohesively identified with their families, kin groups, communities, and other significant groupings" (p. 392) and found it to be valid. Thus, the protective agent of these close familial bonds provides for safety and protection within the community. However, "a Hindu family leaving India . . . will experience the forces of transition from the security of a close traditional extended family to the isolation of a nuclear family" (Landau, 1982, p. 555). If this isolation is coupled with stressors and further decompensation of family bonds, then one can assume that the depressive features could reach dizzying heights.
Finally, Alter-Muri (2002) refers to research conducted on art symbol ism in other countries and states, "Wilson (1985) noted that human figures drawn by 9-12 year olds in Islamic countries had rectangular-shaped torsos and fused necks" (p. 176). Wilson (1985) states:
I have observed this feature in the drawings of children from other countries with Islamic populations—Saudi Arabia, Qatar, Turkey, Iran, India, and
Kenya (although I have not determined the percentages). The feature occurs with such regularity that I have called it the Islamic torso. (p. 92)
Although the patient stated that he was exposed to Western culture prior to his immigration, his drawing ability is in keeping with Table 3.1's description of a 9- to 12-year-old. Thus, I took this into account when scoring and interpreting the final art product (Figure 3.6).
Qualitative Analysis: Details
House: (1) There is no chimney on either drawing, and this is in keeping with the patient's culture, as homes in India do not possess chimneys; (2) the patient places a barlike emphasis on the door of the home in the second figure only (feelings of entrapment, inability to escape present living situation).
Tree: A ground line exists under both trees, with the first being longer and bolder (insecurity in the environment).
Person: (1) The first rendering contains a mouth, which is omitted in the second drawing. The omission could suggest the patient's ongoing difficulty in relating to others due to the language barrier rather than intellectual deterioration. (2) Neither figure's eyes contain pupils (visual processing or learning problems associated with language barrier and/or reluctance to accept stimuli); (3) the fingers are drawn one-dimensionally and without hands (infantile aggression) on the second drawing, while the first drawing's hands are enclosed by a loop (wish to suppress aggressive impulse, repressed aggression).
Qualitative Analysis: Proportion
House: The home is the smallest item in the first drawing and is even smaller in the second (sees, feels, views his family connections as far away in relation to his present environment).
Tree: The tree is very large in comparison to the page in the second drawing (feels constricted by and in the environment).
Person: The person is drawn large in both drawings but is further away (spatial distance) from the home in the second rendering and devoid of a mouth (feelings of helplessness and frustration produced by a restricting environment and physical distance from his home and family).
Qualitative Analysis: Perspective
House: The house in the second drawing is shown from a bird's-eye view and appears far away (rejection of the home situation; however, due to bars on door, may instead indicate a rejection of his present circumstances).
Qualitative Analysis: Comments, Postdrawing Inquiry
Rather than asking the formal questions designed by Buck, I administered the shortened version (for the second drawing only) and requested that the client tell me "what's going on in this picture?" He stated (through an interpreter) that the man has a job and is coming back home. When questioned about the man's age, he said he is 43 years old and that his family lives in the house. He further added that the man is a doctor who is very busy and a nice person. When asked to give the drawing a title or name, he decided to title it "Village Town," which I wrote out (on the left) and which he copied in his own hand.
Qualitative Analysis: Concepts
House: The perspective and spatial distance of the house from the person indicates that in the first rendering the patient may have had more hope for a return to his community and family, while in the second drawing the home is obviously dwarfed by the present circumstances and literal distances.
Tree: In the second drawing the tree is extremely large as well as separating home and person.
Person: Assigning the role of doctor to the person in the second drawing is an interesting mixture of hope for renewal (the doctor has always provided well for the client in the past) and trepidation as the client's present circumstances place him in the position of having to trust unknown professionals. The lack of mouth may symbolize not only the client's growing frustration due to the language barrier but also the family doctor's lack of input into the patient's treatment. In addition, a row of buttons is normal in drawings by Western children until the age of 7 or 8 but afterwards comes to symbolize feelings of inadequacy or dependency. Additionally, the midline that separates the trunk vertically "is frequently seen in schiz oid or schizophrenic individuals whose physical inferiority and mother dependence are in the forefront" (Machover, 1949, p. 89). Although the meaning of this may differ in other cultures, it is interesting to note that it is the second drawing that contains references to dependency and not the first.
Story: The title of the drawing, "Village Town," may represent a combination of two cultures, with the village suggesting India and the town indicating America. It is apparent from this titling that the traditional bonds of family and community remain strong.
Qualitative Analysis: Summary
As noted under cultural considerations, the art of select Islamic countries is typically different from its Western counterpart. Therefore, the score of this projective test takes that into account. In addition, due to the patient's initial drawing of the mouth, I gave him credit despite its subsequent omission, as I consider the exclusion to be due to his increased frustration with his inability to communicate and therefore not an indication of pathology.
Consequently, the HTP raw score is 86 and the net weighted score IQ is 85. This would place him in the low average range of intellectual functioning. His good IQ score correlates to an IQ of 85 and represents his ability to interact in his environment, with a flaw IQ score of 85. Analysis yields that his interests are relatively simple and material in nature. An overview of his detail, proportion, and perspective scores represents an overall stability of functioning with the exception of his perspective good score, which is a measure of insight. This low score coupled with the low score in the proportion flaw indicates difficulty surrounding critical judgment in the more basic problems presented within the environment. The patient's lowest overall scores appear in the drawing of the person, which expresses a significantly low degree of functioning with regard to interpersonal relationships.
Evaluation of his HTP reveals the presence of the following characteristics: (1) feelings of entrapment, helplessness, frustration, and insecurity produced by a restricting environment; (2) a conviction that his family connections are far away and possibly unattainable in relation to his present environment; (3) a growing despondency and dependency.
In conclusion, the patient, estranged from the traditional systems of security previously rooted in his family system, is experiencing increased feelings of inadequacy, despondency, and helplessness.
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