The 20th Congress of RSCANP,

Băile Felix, 18-21.09.2019

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The 42st National Conference of Child and Adolescent Neurology and Psychiatry and Allied Professions with international participation

The role of art therapy in addressing psychopathological disorders in children and adolescents

Autor: Liliana Nussbaum Adriana Cojocaru Ageu Luminița Lorena Garoiu Veronica Cebuc Oana Grimacovschi Mirela Olariu Jan Podhorodetchi Roxana Matu Laura Nussbaum
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SUMMARY Arttherapy plays an essential role in addressing psychopathological disorders in children and adolescents, having an important role in both psychiatry and psychotherapeutic intervention. Use of different art forms such as painting, drawing, collage, etc. it is based on the spontaneity of expression, non-verbal expression of emotions and cognitions overcoming the barriers of verbal communication, being a form of communication and relationship. The main objective is to use creativity in improving and increasing the quality of life by developing personal and interpersonal skills, developing cognitive abilities, self-awareness, managing behaviors and emotions. Key words: art therapy, psychopathology, creation, child

INTRODUCTION The most natural and comprehensive means of solving problems is the creative process. Thus through ART, the fantasy of the child cannot withstand any restraint [4]. Art therapy is a dynamic therapy that combines happiness with art and that in addition to facilitating the acquisition of motor and cognitive skills (concentration, attention, perseverance, logical and abstract thinking, activity planning, patience, imagination and spatial orientation), it also develops interpersonal skills, representing at the same time means of cooperation and communication. It is a form of psychotherapy that strengthens the child’s self-confidence and increases self-esteem, helps him to come into contact with his own emotions and trains his abilities to cope with them, representing an important basis for increasing the quality of life. Art is a complex field of interdisciplinary meetings: of expression, aesthetics, philosophy, psychology, psychopedagogy, psychopathology, clinical psychiatry and sociology. For psychology and psychopathology, art has a specific projective value significance. Art therapy is a therapeutic method that uses creative processes to ameliorate emotional states, psychopathological disorders, dysfunctional behaviors, negative affective states. It has particular value for children whose impairment restricts their ability to participate in other activities [4]. Also, it has a psycho-diagnostic value, providing valuable information on the level of cognitive development, the personality characteristics of the child, his attitudes to stress and social constraints and, last but not least, it gives us the possibility to evaluate the fundamental attitudes towards existence [2, 7]. The creative methods and their interpretation from an analytical-existential perspective represent valuable information on coping reactions and blocking phenomena in a coping reaction. Creative activities open the door to living values, creative values and, above all, attitudinal values. HOW CAN ART WORK AS A THERAPY? In the US this field has evolved in two directions: “Art as therapy” and “Art psychotherapy” [1]. Art as therapy is based on the idea that making art is therapeutic and that the creative process is a growth-producing experience, opening up
communication paths that go beyond the limits of verbal language, expressing emotions that are difficult or even impossible to speak. By giving the child a context in which he can experiment and discover new things, we help him to discover qualities that he had never experienced before. We need the language of art in describing the soul and the depths of reality [5, 6, 8]. Art psychotherapy regards art as a means of symbolic communication through which the personality, emotions and other aspects of the human experience are expressed [5, 9]. One of the basic qualities of art therapists is the ability to adapt to the needs of the patient or group of patients. Many concepts from Freudian psychoanalysis and Jungian analytical therapy, gestalt therapy, humanistic and existentialist thinking have made their mark [1]. Psychoanalytic psychotherapy aims to reveal the outdated material of internalized conflicts that cause problems and help the patient in understanding the meaning of the behavior. A psychoanalytic understanding helps the therapist to determine where a developmental person is fixed; why it is defended. The psychoanalytic approach to art therapy can be a vehicle for change. The ability to form and use symbols represents the raw material of art-therapy, symbolism being a decisive type of mental representation (Beres), the symbol being the conscious derivative of the unconscious mental representation. As the functions of the developing child’s ego mature, the responses to stimuli are almost exclusively mediated through mental representations. Dysfunction in symbol formation characterizes severe mental disorders. The loss of reality testing, the ability to recognize and differentiate between the real object and its representation characterize Schizophrenia. Through art therapy, the repeated expression of key symbols has led to a gradual recognition of their meaning and an ability to differentiate the reality of the ghost. Symbolism plays an important role in the relation of the unconscious to the conscious. Only what is rejected is symbolized and symbolic activity can facilitate awareness, allowing a distance between patient and conflict (Margaret Naumberg – Schizophrenia Art, 1966). Numerous projective tests using drawings provide evidence of this, the diagnostic value of the psychic function of symbolism being indisputable. Art therapy offers the possibility that psychic space, which has much in common with Winnicott’s transitional space, is reorganized by mirror. It is emphasized that the psychopathic personalities had problems in the attachment, the failures in differentiation creating difficulties in discriminating between the internal and external reality encountered in the psychotic states. The borderline personality tends towards fusion states, while the narcissistic personality takes refuge in a grandiose self. Affective disorders are associated with failures in the reappropriation stage. The depressive states of the disposition offer another example of a qualitatively different cleavage from that used by the borderline personality. The deterioration of symbolic functioning is an integral aspect of anorexia, where unconscious mental problems are concentrated on food. The artistic works could provide a way of transition (transactional object) from the concrete obsession with food to a more symbolic form of relationship. Art therapists can provide a supportive environment that can make pain bearable, facilitating “growth.” In the Jungian analytical therapy, certain archetypal themes tend to appear in a predictable sequence. The therapist helps the patient recognize these figures as internal and ultimately integrate them. Phenomenology has influenced psychotherapies, especially humanities. Art-therapy approaches the task with which Heidegger attributed it to phenomenology through the means of the process of free expression, with materials of art freely chosen by the client [1]. In the psychology of art (Kreitler, 1972), structural components of art that convey expressive qualities are described. Round lines, pastel colors can convey warm emotions. Red tones can convey strong, aggressive, but also loving feelings. The sharp-edged zigzag lines are linked to violence. The uniqueness of the phenomenological method of art-therapy consists in the direct experience of the client with his own production which will ultimately lead to the distance under the guidance of the therapist. Emerging from the existentialist philosophy and phenomenology, gestaltism highlights the postulate
of personal responsibility during one’s own life, gestalt therapists challenging their clients towards “growth”, the development of native potential and authenticity. Expressive arts therapy is an integrative multimodal therapy that emphasizes the healing aspects of the creative process. Movement, drawing, painting, sculpture, music, writing are used in a supportive framework, centered on the client who expresses his feelings. The creative process itself is a powerful integrative force. Art therapy offers value and uniqueness to those who are concerned with the transpersonal or spiritual dimensions. The behavioral approach of art-therapy involves the application of techniques to modify the behavior of art-therapy practice and has proven effective in severely anxious and aggressive children [1]. The cognitive-behavioral approach in art therapy has proven to be effective in treating depression, anxiety, insomnia, phobia, posttraumatic stress disorder, schizophrenia and obsessive-compulsive disorder, ADHD, learning disorders and eating disorder. [1]. A cognitive-behavioral technique often used with aggressive children and adolescents, can be amplified by art therapy, by externalizing the internal processes and acquiring the behavioral self-control. Cognitive-behavioral art therapy can be adopted in a wide range of expressive ways. It is used in family and group therapy [1]. Family art therapists combine commitment in the use of graphic expression with commitment in systemic thinking. The family art therapist engages a part, or the whole family of the client, in performing the artistic works, with the therapeutic objective of creating change in the whole family system. In group therapy, both open groups and closed groups are used in artistic workshops. The approach is group-centered, encouraging group members to contribute to the group’s activity. There are three art therapy groups: the workshop-based group, the focus group and the process focus group. The art therapist must submit each aspect of the group’s design, its behavior in the group and how it understands what is happening inside the group. Performing together the artistic work develops a graphic language that allows the clients to talk to each other in ways that cannot be obtained by words alone.
In the period 2017-2019, at the Center for Mental Health in Timisoara and the Clinic of Pediatric Psychiatry in Timisoara, the “Art Therapy” project was carried out with the support of the Sphere of Timisoara Association co-financed by the Administration of the National Cultural Fund and the Municipality of the Municipality of Timisoara. Part of the work done by the children was exhibited at the National Congress of Child and Adolescent Psychiatry and Neurology, held on September 18-21, 2019, at Baile Felix. OBJECTIVES: – The use of art therapy in emotional regulation – Cognitive evaluation of emotion, the process of emotion regulation (through art therapy and targeted psychological therapies) – Evaluation of the factors through which the emotional reaction is redirected, modulated, controlled to allow adaptive functioning through art therapy and psychological therapies. – Applying emotional regulation strategies – Evaluate how the disorder of emotional regulation determines different psychopathological conditions. – Increasing resilience and social competence by developing the process of emotional regulation. WORKING HYPOTHESES – Emotional regulation involves changes in many aspects of emotions, such as the situation that generates emotions, subjective experience and behavior. – Emotional regulation includes processes that change the significance of the event and modulate emotional expression. – The process of understanding and regulating emotions is associated with better psychosocial adaptation, while a distortion of this process favors the appearance of internalization or externalization disorders. – Art therapy facilitates the expression of emotions, promoting compliance with treatment.
MATERIAL AND METHOD In the project “Art Therapy” participated in the period 2017-2019 320 children aged 10 to 19 years, of which 111 were included in targeted psychological therapies.
The data were obtained from the SCM files and observation sheets from the Pediatric Psychiatrists section of Timișoara. The art therapy activity was coordinated by a complex multidisciplinary therapeutic team and a visual artist with a role in technical guidance. Patients with several psychopathological conditions participated in which emotional disorder was the fundamental element. Observation and clinical interview and FO data were used. The method of prototypical diagnosis was approached (Westen and Brandly, 2005). A comparison was made between the patient’s narrative and the prototype description on the basis of which a degree of goodness-of-fitt was established. A qualitative-clinical evaluation was performed in which the patient can be placed in 3 situations from 1 (does not fit) to 3 (fits), 2 being the threshold of the subclinical disorder. The diagnosis of Emotional Regulation Disorder was made using the prototypical diagnosis method. We specify that the disorder of emotional regulation is a factor placed above the categorical diagnoses, being a common denominator of several psychopathological conditions. To measure emotional regulation we used the Scale of Difficulties in Emotional Regulation (Gratz and Roemer, 2004) which is a self-assessment scale with 36 items that reflects the difficulties of regulating emotions in the areas: awareness and understanding of emotions, acceptance of emotions, ability to engage in behavior goal-oriented, finding effective strategies for regulating emotions. The activity in the art therapy workshop took place in stages: the first stage with free productions and the second stage consisted of a dialogue between therapist and patient which in 15% of cases led to overcoming the impasse. Depending on how emotions are expressed, they are classified into Internalizing Emotional Disorders and Outsourcing Emotional Disorders, when they manifest through behavioral changes. Depending on the internalisation and outsourcing criteria, six factors were obtained. RESULTS 1. Art therapy has facilitated active and targeted exploration in Emotional Regulation Disorders from various psychopathological conditions.
2. Depending on how emotions are expressed, the following factors have been identified: – Factor 1 – “Spectrum of internalization disorders” which includes categorical diagnoses: Anxiety disorders, Emotional disorders, Depressive disorders, Schizoid and schizotypal personality disorders. These people have difficulty expressing desires and impulses, with low emotional response (in Depression) or with the predominance of negative emotions (Anxiety Disorders) and increased emotional expressiveness and difficulties in identifying and verbalizing emotions. In bipolar patients there is an increased and prolonged sensitivity to positive emotional stimuli. – Factor 2 – “Spectrum of outsourcing disorders” include people with categorical diagnoses: Behavioral disorders, challenging opposition disorders, hyperkinetic disorder in which there is poor cognitive control of emotions, emotional impulsivity. These people are characterized by hostility, episodes of anger, opposition, lack of empathy. – Factor 3 – Borderline is typical for the inability of emotional regulation, self-destructive behavior, suicide, impulsive acts. These subjects are not able to process emotional stimuli and have unstable internalization and outsourcing strategies. – Factor 4 – Neurotic was found in those with a lower level of dysfunction compared to those in the previous categories. Categorical diagnosis: Emotional disorders. If the features are of clinical intensity, they are found in the categorical diagnoses of OCD (Obsessive Compulsive Disorder) and Histrionic Disorder. – Factor 5 – Disruptive mood disorder (DSM5) – Characterized by episodes of sadness, daily irritability and disproportionate emotional reactions starting at age 10. – Factor 6 – Dysphoria, is found in depression, anhedonia. 3. Integrated psychological treatment consisted of a unified treatment protocol for transdiagnostic emotional disorders that aimed to improve the ability to regulate emotions, which is crucial for emotional intelligence involving the processing of emotional information. 4. Psychopathological art is not only a particular form of expression, but a form of designing the intrapsychic morbid content.
5. The longitudinal analysis of the pathoplastic creations and the modification in time of these creations provided useful information in establishing the 6 factors described and the type of evolution, being an indicator of the prognosis of the disease. 6. In the complex rehabilitation process, art therapy has contributed to a “self-healing” by its own means. DISCUSSIONS The analysis of the pathoplastic creations and the changes under treatment revealed the following psychopathological characteristics: In the psychotic patients, the creations showed a strange reality, a world of hallucinations, delirium, symbolic, stylized, bizarre-fantastic creations, stereotypes and experiences of derealization / depersonalization. In the cases with chronic evolution, negative symptoms, with ideo-verbal dissociation, the disorganization of the forms is found through a dissolving-dissociative process, the creations having the appearance of indecipherable and incomprehensible scum. Patients with OCD are characterized by difficulty in starting the art therapy activity due to the compulsions of touch, the rituals of ordering, the indecision and the need for perfection. Their drawing highlights the concern for details, symmetry and abstraction, bringing it closer to the characteristics of drawing patients with schizoid disorders, schizotypal disorders or epileptics with intercritical psychiatric disorders. Another characteristic of the artistic style of these patients is the repetition stereotype (stereomorphism) There were similarities between the artistic style of some patients in the obsessive-compulsive spectrum with little or no insight with those in the body dysmorphic disorder, mental Anorexia and those in the schizophrenic spectrum. On the other hand, the episodic and comorbidity evolution of some patients with OCD puts its mark on the pathoplastic creations, approaching them with those of the bipolar disorder. Patients with externalizing disorders such as Behavioral Disorders, Oppositional Disorder, Hyperkinetic Disorder are hardly involved in the activity, have difficulty completing, have low interest. Their designs are characterized by inequality and sometimes content poverty, which means the inability to sense and recognize emotions and low access to emotional regulation strategies. The same inability to adjust emotionally with instability in perceiving the head was also found in patients with Borderline Personality Disorder. Their creations reveal emotional confusion, impulsivity, self-destructive behavior. An inability to tolerate and regulate negative emotions is also found in patients with substance or alcohol use and in patients with eating disorders, especially in Bulimia nervosa, where impulsive and excessive consumption is a mechanism for regulating negative emotions .
CONCLUSIONS In conclusion, emotional regulation is a conscious form that involves changing the meaning of what is perceived and reevaluating the emotional stimulus by changing the way the person thinks about the situation and finding alternatives to monitor how the emotional response to change the emotional state. “Music and art are perhaps the best examples of how cognitive processes recruit primary emotions, activate them, and together form an extremely complex emotional life” (Watt, 2004) [10].
BIBLIOGRAFIE / BIBLIOGRAPHY 1. Iudith Aron Rubin Art-terapie – terapie și tehnică, ed. Trei 2009. 2. Frankl, V.E., Man’s search for meaning, Boston, ed. Beacon 1969. 3. Enătescu Constantin „Artă și nebunie”, ed. Arpad Harangoza, București 2006. 4. Nussbaum Laura – Abilitarea și reabilitarea psihiatrică la copil și adolescent, ed. Artpress 2011. 5. Cebuc Veronica, „Ghidul art-terapeutului”, ed. S.C.Portos SRL, 2019.
6. 7. Frankl, V. , Man’s Search for Meaning, New York, Washinton Square Press, 1984 8. 9. 10. Watt D.F. (2004) Consciousness, emotional self-regulation and the brain, review article, Journal of Counsciousness, Studies, 11(9):7782.