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Case Study: "Wanda Offenbach"

"Wanda Offenbach" - Genogram
"Wanda Offenbach" - Genogram
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All people referred to in case studies, except for the writer, have been de-identified to protect their privacy.

 

Follow this link to view this case study in PREZI format

 

 

Introduction

 

  • This case study presentation was prepared by Colin Read, whilst on internship as a La Trobe University Master of Art Therapy student. The primary purpose of this case study was as a report to the Clinical Placement supervisor and peers. It was given as part of the assessment requirements for the subject, Clinical Placement A (PHE4ACA), Semester 2, 2012 at La Trobe University in the Graduate Diploma of Art Therapy course (1st year of the Master of Art Therapy).
  • The client that this case study presents was referred by the Art Therapy Student's location supervisor, who was an Occupational Therapist (OT 2), employed on a full-time basis at the Hospital's Secure Extended Care Unit (SECU).
  • The SECU is an inpatient residential unit whose primary clientele are psychiatric patients on Involuntary Treatment Orders (ITOs). A small percentage of the clients are voluntary patients. The maximum population that the unit can cater for is 28, with facility for both men and women.
  • Each patient has their own lockable room, with bed, shower and toilet facilities. There is a common lounge area with television as well as a billiards and table tennis area. Central to the ward is the nurses' station from which most common areas are visible.
  • There is one outdoor area with seating, and a second outdoor area that is currently set up as a vegetable garden project by the OT.
  • The art area is a room measuring approximately 4 by 5 metres, and is situated opposite the nurses' station. It has two large trestle tables, a sink and cupboards for storage. The flooring is vinyl and the walls facing the nurses' station are completely glassed in for maximum visibility.
  • Material offered for art activities and art therapy include acrylic paints, marking pens, pencils (coloured and a range of grey lead), magazines for collage, playdoh, and tiles.

Background

Family

"Wanda" is a 34 year old female, of Australian and German heritage. Her father separated from her mother when she was 6 years old and died of suicide when she was 10. She has an older brother, Charles, and a step-sister from an earlier marriage that her father was in before he met her mother. She is aware that there are a further two step-brothers from this earlier marriage, but she does not know where they live. She maintains a close relationship with her mother and her step-sister, who is also in a good relationship with "Wanda's" mother. Her brother is actively hostile toward her and he also has a hostile relationship with her mother. Her mother visits her on a weekly basis whilst she is in the SECU and has talked with the writer on some of these occasions. Whilst these meetings have not been formerly organised, "Wanda's" mother has taken opportunity on these occasions to talk extensively with the writer about "Wanda's" educational history and past art activities.

Education and Onset of Illness

Throughout Primary and Secondary school, "Wanda" was "gifted" in maths and science based subjects. There are anecdotal stories of her being able to "just know" the square of numbers (e.g. 58 squared is 3364) when she was only 7 or 8 years old. In Secondary School, biology and physics were two of her best loved areas of study. "Wanda" has achieved the first two years of Bachelor of Arts (Urban, Regional and International Development) Monash University, but failed to complete the final year due to the onset of her illness. This was in 2000, and was her first diagnosed episode with Schizoaffective Bipolar Disorder at the age of 22. Generally observed by her parents, her step sister, and some educators as being a "bit of a loner", it was never a major concern as she was able to be sociable when required and was not anti-social in her overall behaviour. In retrospect, her mother believes it was a failure of educational and health professionals for not picking up on the "autistic nature" of "Wanda's" behaviour when she was younger so that "something could have been done about it before her first getting really sick". It is now believed that "Wanda" is situated on the Autism Spectrum with some high functioning form of Asperger's.

Treatment History

Although "Wanda's" illness is generally well managed with medication, she regularly stops taking her medication. The longest continuous period she has stayed on her medication for is approximately 4 years and 3 months. When she discontinues her medication, it results in her becoming a danger, physically, to herself and others. As a result she has been on Community Treatment Orders, which she tends to break by refusing her medication, "going bush" and ceasing contact with her case manager, resulting in Involuntary Treatment Orders and subsequent admission to locations such as the hospital's SECU. Whilst hospitalised, "Wanda's" illness is well managed with "Wanda" presenting no management problems. She spends a large amount of time in her room reading novels, but is compliant when asked to come out her room in order to interact with staff and other patients, which she does in an appropriate manner. "Wanda" also attends various programs such as SECU community meetings, music therapy sessions, and goes on escorted leave to the local library. Because of "Wanda's" flight risk, unescorted leave is not permitted at this stage.

Context of Art Therapy

"Wanda" was referred to Art Therapy by the SECU Psychiatric Registrar via the Occupational Therapist. During ward rounds the subject of "Wanda's" tendency to stop taking medication and go "AWOL" was discussed. It was also noted that she spent a lot of time alone in her room, reading. It was hoped that "Wanda" would be agreeable to doing some one to one, as well as some group, Art Therapy sessions. The main objectives were seen to be to promote social interaction; get her out of her room; and, possibly, encourage her to reveal something of the motivations and thought processes present when she goes off to the bush and neglects her treatment and medication.

First Session - One to One

Wednesday August 8, 2012. 11:00am - 12:15pm
The main objectives of this initial session were to establish a trusting and safe environment for "Wanda"; to explain the expectations and process; and to undertake initial assessment into "Wanda's" readiness and willingness to do Art Therapy sessions.

Content of Interview:

  • "Wanda" was invited to participate in a one to one Art Therapy (ATh) session and was responsive to the request. She was shown some options for what she could do – Silver Drawing Test based activity; Mandala; drawing of choice with material of choice. Basic ATh philosophy was also explained to Wanda. Wanda chose to work on A3 paper with a grey 3B pencil. She drew a kookaburra in a gum tree and worked for some time to fill in the background with scrub and bushes.
  • The scene was based on the surprise of unexpectedly seeing a kookaburra in a tree when Wanda was camping once. She said it was a good memory and seeing the kookaburra had been a nice surprise. Wanda spent some time detailing the tree bark, the kookaburra's feathers and the under brush plants.
  • A finish time of midday had been originally negotiated, since this was when lunch was usually served, A 5 minute warning was offered at 11:55am, but Wanda continued to work on task for a further 15 minutes beyond the initially negotiated finish time in order to complete the drawing. Given the choice to work further on the kookaburra drawing; finish up for the day or do another drawing, she chose to finish, since she was already late for lunch and she said she was hungry. She also said she had an idea for her next drawing which would probably be a kangaroo or some other type of Australian native animal.

Second Session - One to One

Friday August 10, 2012. 10:30am - 12:00pm
The main objectives of this second session were to continue in the establishment a trusting and safe environment for "Wanda"; and to undertake ongoing assessment into "Wanda's" willingness to do Art Therapy sessions. It was also an opportunity to continue on from where we had left off. I was interested to see if "Wanda" would pick up on the idea she said she had for a drawing when we finished the previous session.

Content of Interview:

  • "Wanda" immediately said that she knew what she wanted to draw. Once again she chose a 3B grey lead pencil from the variety of media available which included coloured pencils, marking pens, oil pastels and acrylic paints. Working on an A2 sheet of paper, "Wanda" proceeded to draw a country scene with kangaroos "grazing" in a paddock in the foreground. It was noted in discussion that she obviously liked the bush and countryside and "Wanda" said it was the main thing she always drew.
  • "Wanda" spent some time drawing in the grass. Of particular importance to "Wanda" was the "fur" of the kangaroos, which she took the most time to do. She also was humming to herself during this process. She also reinforced the kangaroos by heavily going over their outline with the grey lead pencil.
  • Some discussion took place around the idea of textures with reference to the kangaroos' fur and the bark of the gum tree in her previous drawing.

Third Session - "Group"

Friday August 17, 2012. 11:00am - 12:00pm
The main objectives of this third "group" session were to see if "Wanda" would be open to doing art in the presence of others; to offer the "scribble" exercise to see what thematic content "Wanda" would come up with and to undertake ongoing assessment into the suitability of Art Therapy sessions for "Wanda".

Content of Interview:

  • The "group" consisted of 3 clients including "Wanda". When invited to do artwork of their own choice or to try the "scribble" drawing, all participants said they would be interested in doing the "scribble" drawing. The writer explained and demonstrated the technique and invited each participant to close their eyes and commence their own "scribble". "Wanda" started her scribble with her eyes open, but closed them when reminded that it works best when eyes are closed.
  • When the stage came to consider the "scribble" and look for an image in the "scribble" she was quick to start drawing out background hills, followed by water and waves in the foreground, and rocks and sand midway. "Wanda" talked about the times she would go to the beach and how much she liked to be on a deserted beach with no-one else around.
  • Some discussion took place in the group about favourite places to be and the other members of the group shared what they had drawn out of their "scribbles".

Fourth Session - One to One

Monday August 20, 2012. 1:00pm - 2:30pm
The main objectives of this third "group" session were to see if "Wanda" would be open to doing art in the presence of others; to offer the "scribble" exercise to see what thematic content "Wanda" would come up with and to undertake ongoing assessment into the suitability of Art Therapy sessions for "Wanda".

Content of Interview:

  • We started the session by revisiting "Wanda's" oil pastel "scribble" drawing which was done in the previous "group" session. "Wanda" commented on how she liked the scene and the memories of being at the beach. She also made mention of the colours and the writer invited her to do a coloured picture during this session. "Wando" said that she didn't like the "runniness" of paint but liked the look of paint and that she would like to try something different to the oil pastels if doing something with colours.
  • Choices offered as a consequence of this line of discussion were marking pens, Posca paint pens or the option to use grey lead remained open as well. "Wanda" decided to try the Posca paint pens and quite enjoyed their "painty" effect with the control of a marking pen.
  • The thematic content of "Wanda's" drawing was a version of the previous "scribble" drawing's beach scene. Once again it was noted that "Wanda" spent a lot of time working to fill in all the "white" area of the paper.
  • Discussion once again centred around "Wanda's" love of the beach, the bush and nature.
  • Looking back over this and previous drawings I noted that she never included a sky in any of her drawings. When this was pointed out she briefly acknowledged the fact, but made no further comment and continued on with the sand and grass section of her drawing. Prior to this she had been humming to herself but this did not continue.

Fifth Session - One to One

Monday August 27, 2012. 1:30pm - 2:20pm
During this fifth session the main objectives were to allow "Wanda" to explore the use of Posca paint pens further; to invite "Wanda" to do a drawing of her favourite type of weather; and to continue in the consolidation of a safe and trust-based environment.

Content of Interview:

  • During initial discussion about what we would do this session "Wanda" said that she had enjoyed using the Posca paint pens and was happy to work with them again. "Wanda" said she was unsure as to what to draw and asked the writer to suggest something.
  • The Art Therapy Student made a couple of suggestions which included using the Silver Drawing test images; "Where I'd Like to be Right Now"; or "My Favourite Weather". "Wanda" remained uncertain and the Art Therapy Student encouraged "Wanda" to "Try drawing your favourite type of weather - just the weather conditions... hot, sunny, cold, rainy, snowy, cloudy... whatever weather you like best."
  • "Wanda" quickly drew the sun in the top corner of the page. This took her about 5 minutes.
  • The remainder of the session was spent on the landscape and "cattle" section of the page, with the windmill and fence on the horizon line.
  • Just before 2:20pm "Wanda" said she wanted to go and have a cuppa and would finish later.
  • Before she left the writer asked her what still needed to be done, thinking she would talk about finishing or putting in more of the sky, but she said that she had forgotten to put in a water tank next to the windmill and this is what she wanted to add.
  • "Wanda" went off to get a cuppa and returned soon to say that she had decided not to do any more on the drawing and was going to go and do some reading.

Sixth Session - Escorted Leave

Monday September 3, 2012. 10:30am - 11:45am

Content of Interview:

  • "Wanda" and two other clients were taken to the local library by the Occupational Therapist and the writer. The writer felt that this would be an opportunity to continue with the consolidation of the trust relationship required in the Art Therapy sessions.
  • At the library "Wanda" showed a high level of independence, using the computer catalogue system to find books, making enquiries of the library staff and checking out the books.
  • "Wanda" chose a Bryce Courtney novel, a book about early Australian bushrangers, and a biography of Marie Curie.

Seventh Session - One to One

Monday September 3, 2012. 1:15pm - 2:00pm

Content of Interview:

  • "Wanda" approached the writer when writer returned from lunch and requested to have a one to one session. "Wanda" presented as agitated and restless and when she entered the art therapy room she started talking about current frustrations on the ward. Essentially she was worried that some of the aspects of being hospitalised were exacerbating her illness and causing her to become agitated and aggressive. Her main concerns were:
    • a feeling of a lack of freedom and ability to move about when and where she pleases
    • a lack of intellectual stimulus and conversation
    • mixing mainly with other sick people
    • the general level of aggressive behaviour and interactions currently on the ward due to some of the patients getting illicit drugs smuggled in
    • a sense of being shut in by the architecture of the ward - even though there is an outdoor area it is enclosed by a high wall and when you are indoors, even when you can see the outdoor area, there is still no feeling of openness.
  • "Wanda" was also concerned that she may be in risk of physical attack since she had openly told the staff who was getting drugs in and how.
  • The writer spoke with "Wanda" about the possibility of running a group art therapy session where the main focus would be on social interaction, sharing of ideas and cooperation. She thought this would be a good idea, but wondered about the ability of people to commit to it in the light of their varying levels of illness.
  • "Wanda" did not want to do any art during this session, but said she would be happy to do more Art Therapy later in the week as well as talk more about the issues of being on the ward and the possibility of a cooperative art group.

Where to Now?

Theory and Practice...

The writer believes he needs to develop and consolidate his understanding of schizophrenia in general and the application of Art Therapy in the context of schizophrenia in particular. Literature and specific theoretical applications to explored include:

  • The development and implementation of "self strengthening" exercises based on the model described by Spaniol (2012) in Malchiodi's "Handbook of Art Therapy - 2nd Edition" (2012)
  • The implementation of a phenomenological approach in order to discuss art and issues within the context of the "here-and-now". This would also entail drawing from reality (e.g. still life) in order to assist the client to rely on objective observation and consolidating cognitive awareness within reality rather than fragmentary imagery based on imagination (Crespo, 2003; Wadeson, 2010)
  • Taking into consideration results of studies such as The Matisse Study (Crawford et. al., 2010; Crawford et. al., 2012)
  • More exploration within a one to one setting with "Wanda" re outdoors and bush themes, perhaps using collage in order to provide realism of content and geographical location.
  • Explore the potential and feasibility of a regular group session focusing on interactive, cooperative and shared dynamic art therapy experiences.

 

As an Art Therapist, I have learnt that it is important to be open and responsive to the needs of the client, within the context of the clinical setting.  This includes not forcing the client to fit into organised or structured activities, but being open and flexible enough to offer the client appropriate interaction and process to suit their needs at the given moment of the therapeutic encounter.  This may mean simply talking through issues with the client rather than insisting on engaging in art making. 

Finally, during the undertaking of this case study, the author explored some of the aspects of “Wanda’s” art making process.  This entailed reproducing her work, “Kangaroos” in order to experience what the author had previously referred to as perseveration.  In retrospect, after doing this exercise and further observing “Wanda” engaged in similar processes, the action of detailing such things as grass and kangaroo fur, although repetitive, is now considered by the author to be a relaxing practice, allowing “Wanda” to “escape”, in kind, into the flow of the process.  It does not have the compulsive or “uninterruptable” aspects of perseveration.

 


 

 

References

American Psychiatric Association. (2000). DSM-IV-TR (4th Edition ed.). Washington: American Psychiatric Association.

Crawford, M. J., Killaspy, H., Kalaitzaki, E., Barrett, B., Byford, S., Patterson, S., . . . Waller, D. (2010). The MATISSE study: a randomised trial of group art therapy for people with schizophrenia. BMC Psychiatry, 10(65). doi:10.1186/1471-244X-10-65

Crawford, M. J., Killaspy, H., Kalaitzaki, E., Barrett, B., Byford, S., Patterson, S., . . . Waller, D. (2012). The MATISSE study: a randomised trial of group art therapy for people with schizophrenia. (344(e846)). doi:10.1136/bmj.e846

Crespo, V. R. (2003). Art Therapy as an approach for working with schizophrenic patients. International Journal of Psychotherapy, 8(3), 183-193.

Ruddy, R., & Milnes, D. (2009). Art therapy for schizophrenia or schizophrenia-like illnesses (Review). The Chocrane Library, 2009, Issue 1. Wiley. Retrieved from http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003728.pub2/pdf

Spaniol, S. (2012). Art Therapy with Adults With Severe Mental Illness. In C. A. Malchiodi, & C. A. Malchiodi (Ed.), Handbook of Art Therapy (p. 298). Guilford Publications.

Wadeson, H. (2012). Art Psychotherapy, Second Edition. Hoboken: John Wiley & Sons., Inc.

Weinberger, D. R., & Harrison, P. J. (Eds.). (2011). Schizophrenia (Third Edition ed.). Wiley-Blackwell.