Here: the case of a woman with bipolar disorder who was admitted for aggressive behavior and nonadherence to medications. Art therapy and pharmacotherapy played a pivotal role in her recovery.
Figures 1, 2, 3 and 4
Art therapy is defined by the American Art Therapy Association as “a mental health profession in which clients, facilitated by the art therapist, use art media, the creative process, and the resulting artwork to explore their feelings, reconcile emotional conflicts, foster self awareness, manage behavior and addictions, develop social skills, improve reality orientation, reduce anxiety, and increase self-esteem. A goal in art therapy is to improve or restore a client’s functioning and his or her sense of personal well-being.”1
Individuals with mental illnesses may not always be verbally expressive; however, they may display emotions through creative expressions such as music, poetry, or art. The use of art also helps them reflect on their thoughts, desires, and challenges. Vincent Van Gogh projected his turbulent emotional experiences onto the canvas.2,3 He once said: “What lives in art and is eternally living, is first of all the painter and then the painting.”3 More recently, the work of Mexican artist Martin Ramirez was exhibited at the American Folk Art museum in New York. Ramirez had schizophrenia and spent most of his adult life institutionalized.4
We present the case of an elderly woman who had a long history of bipolar disorder who was admitted for aggressive behavior and nonadherence to medications. Art therapy along with pharmacotherapy played a pivotal role in her recovery.
Mrs Robinson, a 78-year-old white nursing home resident with bipolar I disorder, is admitted for agitation. Her psychiatric history is complicated; she had multiple exacerbations and hospitalizations and is nonadherent to her medications.
During the first week, she is agitated, abusive, and preoccupied with religious and sexual perseverations, specifically about homosexuality (Figure 1). While in the hospital, the medications she had been taking at home are continued, although her risperidone dosage is increased. She shows some improvement, but by the second week, she becomes more agitated and intermittently refuses medications. She draws a picture of herself in a bathtub (Figure 2). Valproic acid for further mood stabilization is added.
In spite of her agitation, she participates in art therapy. Her artwork is closely observed and interpreted by a trained art therapist. Mrs Robinson does not engage in any conversation with the treatment team; however, her drawings frequently demonstrate the fluctuations in her mood. With symptom improvement, she joins other structured art activities, such as painting boxes and decorating charts with feathers and other embellishments. She plays the piano and enjoys watching the news and talk shows. She makes a portrait of a famous comedian in the second week (Figure 3).
Mrs Robinson gradually improves, she becomes noticeably cheerful and polite, and her drawings seem to reflect more positive themes (Figure 4). She is discharged after 4 weeks.
The content of the initial drawings highlighted preoccupation with religion and sex, which corresponded with her thought process. All initial drawings used heavy pressure and strokes along with more use of black and red colors, which were also consistent with underlying aggression and anxiety (Figures 1 and 2).
When therapeutic alliance was established in subsequent weeks and medication adherence improved, positive changes appeared in her drawings as evidenced by reduced aggression in themes and line quality, and a less restrictive range of color (Figures 3 and 4).
The act of creating art is connected with sublimation, a secondary defensive process defined as “a creative, healthful, socially acceptable, or beneficial resolution of internal conflicts between primitive urges and inhibiting forces.”5 Using art, Mrs Robinson seemed to sublimate some aspects of her life that she had defined as “perverse” into something socially acceptable, and the combination with pharmacotherapy worked well.
Although not a substitute to pharmacotherapy, art therapy can give a sense of control to patients with mental illness. It encourages self-expression, enhances coping skills, reduces stress, and boosts self-confidence. Different art forms (eg, theater, music, dancing) are effective means of self-expression. A survey identified improvement and benefits in stress reduction, therapeutic benefit, improved sociability, and skills development.6
Art therapy effectively engages patients and allows the release of emotional tension in a contained manner. This allows relaxation, improved mood, and reduction in painful and troubled emotions. Art therapy has proved useful for patients who have PTSD, anxiety, and depression.7,8
With its roots in psychological projective testing, art therapy assessment has been used to collect diagnostic, psychodynamic, and psychological data related to the treatment process.9 Several diagnostic assessments have been tested for both reliability and validity, including the Diagnostic Drawing Series10 and the Formal Elements of Art Therapy Scale.11 Findings on these two tools indicate a correlation of the graphic elements observed in artwork and specific DSM diagnosis.
Art therapy is low cost with virtually no adverse effects, and it can serve as a means of symbolic speech for patients who have difficulty in expressing their emotions-visual art can be employed as a means of speaking from the self. Art therapy is a form of self-expression, which can be less threatening to patients experiencing significant mental distress. It is easily used in both inpatient and outpatient settings, and it can be beneficial for patients for whom pharmacotherapy is contraindicated. It is a validated intervention for patients with cognitive or intellectual deficits who are unwilling or unable to participate in other forms of therapy.
A patient’s strengths and interests in any form of art, such as painting, music, or dancing, should be assessed during the initial evaluation and in group therapy sessions. Treatment plans can then be tailored to include individualized sessions with an art therapist based on the patient’s skills and level of understanding.
Dr Maheshwari is a Psychiatry Resident at the Einstein Medical Center in Philadelphia. Ms Ordner is an art therapist at Indiana University-Purdue University Indianapolis and Community Health Network. Dr Agarwal is a Psychiatric Resident at the Einstein Medical Center. Dr Retamero is the Associate Program Director at the Einstein Medical Center. The authors report no conflicts of interest concerning the subject matter of this article.
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