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Case Study: "Carmelisa Pizzato - 'In The Room With Me Close'"

Carmelisa Pizzato -
Carmelisa Pizzato - "Genogram"
Carmelisa Pizzato - "Genogram"

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

The following case study took place in the setting of the Neuropsychiatric Unit of one of Melbourne's major hospitals. As an art therapist, this setting presented a range of interconnected challenges in clientele, infrastructure, and working model, as well as personal, professional and practice development. Throughout the placement there was a constant interplay of dynamics which both stretched me out and kneaded me into new forms, just as we did with the “slime” which features in one of the sessions presented later in this case study.

In many ways I fear this case study will not do justice to the lively and beautifully naïve character of the case report subject – it will be difficult to convey her “voice” in the written text. It was this that influenced my decision to do the case study using the character voices of those involved.

The simplicity of the client’s nature and the elements of her uncomplicated acceptance of how things are for her has influenced me as an art therapist as powerfully as any unfolding of insight into existential truth might do (Cooper, 2003; Moon, 2009; Yalom, 2007).

1. Challenges of the Placement Environment

In this section I present issues and challenges related to working within the hospital’s Neuropsychiatry Unit. In particular, I discuss issues concerning the unique nature of the clientele; the unit’s infrastructures; and the unit’s working model ("NEUROPSYCHIATRY UNIT", 2013).

1.1. The Neuropsychiatric Unit – Clientele, Infrastructure and Working Model

During the second semester period of my placement at the Neuropsychiatric Unit, the unit admitted 73 patients, mostly by referral. The admitted patients were suffering from various forms of neuropsychiatric and neuropsychological illness. Prevalent presenting conditions included Huntington’s Disease (HD) (Huntington's Victoria, n.d.); Young Onset Dementia (YOD) ("The Lovell Foundation", n.d.; "Younger onset dementia", n.d.); and Frontotemporal Dementia (FTD) ("Frontotemporal dementia | NeuRA - Medical Research Institute", n.d.). As well there were a range of rarer conditions such as Neimann-Pick type C (NPC) ("More about Neimann Pick Type C disease", n.d.); Velo Cardio Facial Syndrome (VCFS) ("VCFS", 2010); and various gene based anomalies which resulted in unusual neuropsychiatric presentations (Stokes, November 7, 2012).

Physically, the unit is unlike most other hospital wards, having six single rooms and one double room, each with an en suite. In addition patients are encouraged to perform daily living tasks such as making their beds and keeping their rooms tidied; take their meals in a common dining area and make use of the inpatient kitchen area. There is also a common lounge area with a television; an activities room; and a small balcony with a range of patient maintained potted plants. There are also a range of games, books and activities including word-find puzzles, Sudoku and model making kits and patients are encouraged to make use of these during the quiet periods between testing.

The unit’s staffing falls into a range of categories – medical, including neuropsychiatrists and neuropsychologists; allied health, including a welfare worker and an occupational therapist; psychiatric nursing staff; as well as cleaning and unit aide personnel. Additional specialists – speech therapists; physiotherapists; pain specialists; radiologists; and medical imaging specialists – are often called upon for further client investigations.

The primary working model of the unit is a diagnostic medical model. Patients are admitted by referral in order to benchmark and monitor the progress of a diagnosed illness, or they are seen in order to try to determine a diagnosis. The clientele referred to the unit are not limited by geographic location. During the period 2008-2011, 57% came from Melbourne urban locations, 39% from Victorian rural locations and 4% from interstate (Stokes, November 7, 2012).

In some cases the nature of an illness may not be immediately clear from the client’s set of symptoms. In these situations an extensive range of tests are undertaken to arrive at or exclude a particular diagnosis, or in order to determine the balance between the physiological and psychological genesis of the manifested symptoms. There are times when a decisive diagnosis cannot be arrived at and a working diagnosis is determined as the “best fit” from a list of differential diagnostic possibilities (Gilman et al., eds., 2010).

2. Introducing Carmelisa Pizzato

This section describes the case study subject, Carmelisa Pizzato and my interactions with her. I discuss her personal, developmental and medical history, as well as present a summary of the art therapy sessions undertaken. This information is also considered in the context of applicable therapeutic and philosophical theoretical frameworks which influenced and informed my interactions, clinical decisions and professional development throughout the process of working with Carmelisa.

2.1. General Overview – Personal and Developmental History

When I first met and worked with Carmelisa, who adamantly insisted on being called Lisa, she was a 45 year old woman who presented in appearance as younger than her age. Lisa was the third child in a sibship of 4, having an older brother and sister and a younger step sister. She claimed her young appearance was due to her biological mother’s “good genes” (Pizzato & Read, September 16, 2013). Lisa’s biological mother had passed away from “something in her brain” (Pizzato & Read, September 16, 2013) when Lisa was aged 1 or 2 years. Since the age of approximately 3 years Lisa had been raised by her step mother whom she was in a very good supportive and loving relationship with. Lisa’s father had died in 2011, and subsequently Lisa had continued to be supported by her step mother and siblings (see "Genogram: Carmelisa Pizzato").

Educationally, Lisa had been below average and had struggled somewhat academically. She had left school in year 10 and had worked on and off over the years as an assistant in a chemist shop, but eventually due to issues related to her condition had stopped working and gone onto the disability pension.

Because of her condition (which will be discussed further below) she spoke with a husky voice and her speech had a simplicity about it indicating some form of mild intellectual disability. Lisa had some insight into this and stated that when she met people, because they were likely to think she was a bit simple, she would smile with a big smile in order to relax them thereby making them feel happy and comfortable with her (Pizzato & Read, September 16, 2013).

Having read Lisa’s case notes and heard about her in a ward round prior to first meeting her, I was keen to engage her in some art therapy sessions on two levels.

Firstly, I was curious to explore how her developmental history might have impacted on her, particularly with reference to issues of attachment, separation and individuation, in the loss of her mother when she was only an infant and the subsequent relationship with her step mother. How was she effected in terms of a rift in symbiosis and subsequent disruption in rapprochement and object constancy (Bergman & Ilan, 2004; Mahler, 1967) following the death of her mother? Family dynamics also intrigued me with the interplay between biological siblings and a step sister. I was also interested in seeing if there were any issues related to her father’s recent death which she felt may need exploration in terms of grief and anxiety.

Secondly, I was interested in working with her because of what the Neuropsychiatry Unit’s medical team suspected would prove to be her diagnosis. In my previous 2012 placement at a Secure Extended Care Unit (SECU) I had worked with a young woman who had a condition known as Velo Cardio Facial Syndrome (VCFS) or deletion 22q11. She had presented with severe auditory and visual hallucinations and constantly chattered with her inner voices, rarely communicating with those around her. It was strongly suspected that Lisa’s testing would show that she too had VCFS and I was keen to work with her in order to see another side of this condition and help to reframe my single experience misconceptions concerning the syndrome

2.2. Medical History and Presenting Issues

Lisa presented to the Neuropsychiatry Unit with a range of medical issues. The primary reason for her admission was to help with the control of a tremor in her hands and upper limbs, with her right hand being the worst.

Lisa had a history of schizoaffective disorder which had first been diagnosed when she was aged 29. She had first been hospitalised with a major episode in 2004. Lisa displays predominantly negative schizoaffective symptoms when she is unwell and manages her illness with a range of medications including clozapine, valproate, aripiprazole and benztropine. One of the aspects of her admission to the Neuropsychiatric Unit was to review her medications in order to “tailor” and adjust those which may be exacerbating her tremors. She also had epilepsy which was generally controlled by medication.

Lisa had previously been admitted to the Neuropsychiatry Unit in 2006 following a suicide attempt by medication overdose. During that admission a working diagnosis of cross-linked periventricular heterotopia was arrived at. Periventricular heterotopia is a neurological illness in which “nerve cells (neurons) do not migrate properly during the early development of the fetal brain” ("Periventricular heterotopia," 2013). There were, however, issues with this diagnosis as it is usually caused by a filamen-A protein mutation, and there was no such mutation found in testing at the time.

With hindsight it was thought that during the current 2013 admission she should be tested for Velo Cardio Facial Syndrome (VCFS or deletion 22q11) ("VCFS," 2010). This diagnosis possibility had not been tested for in her previous admission, but testing methods had progressed to the point where it now involved a simple blood test, albeit with a 5 to 6 week turnaround.

Cognitively, Lisa presented as below average and was very concrete and rigid, often becoming literal and stuck in her thinking. As previously mentioned, she had some insight into this and was happy to put people at ease by her friendly, open and welcoming nature. She could also give a bit of cheek and wasn’t beyond being gregarious and playful when interacting with others.

Purely on a medical level, there were many considerations to be taken into account when planning to undertake art therapy session with Lisa. Her medication regime meant that I had to be aware of the possibility of “dulling” in her responses, both physically and cognitively. Negative aspects of her schizoaffective disorder also meant that there may be occasions when she would be withdrawn or unwilling to participate. Her tremor would likely cause concern for her when asked to do things that required fine motor skills. It was noted that she was self-conscious about the tremor and often used her better hand to hold and control her shaking hand when doing basic tasks such as eating and using utensils, usually waiting until other patients left the table before commencing her own meal.

3. Art Therapy Sessions and Overview of Related Theoretical Reasoning

When planning to undertake art therapy sessions with any of the clients on the Neuropsychiatry Unit I usually do a minimum of two planned sessions and, depending on whether or not the client is willing or capable of continuing, I will structure further sessions exploring and extending themes and requests arising from those two initial sessions.

This was no different for my time with Lisa, the first session being a period of informal introduction to what my role in the unit’s team was, an explanation of what art therapy is about , a time of establishing trust and a sense of safety, and a request (or invitation) that she do an initial art therapy session with me.

During this introductory session I very much hold to a “Rogerian” model of having some sort of minimal relationship based on genuineness, unconditional positive regard, and empathy (Rogers, 1957). In my ongoing interactions with clients I am also very conscious of the need to provide a safe place for the client to interact with myself, the creative process and the created work in the present moment. This allows opportunity for existential contemplation (Cooper, 2003; Moon, 2009), a sense of being held, contained and going on being with a freedom to dream and explore (Ogden, 2004).

The second sessions that I always try to undertake with a new client is to invite them to do an Expressive Therapies Continuum (ETC) (Hinz, 2008; Hinz, 2009; Lusebrink, 1992) choice exercise in which I ask the client to freely select from a broad range of media and create whatever they like with it. The only criteria I impose is that they spend at least 15 minutes in the session after which time they are free to continue or leave should they wish to do so.

Working with Lisa, I used this exercise to observe and note her stated preference of materials (textas, pens and collage); her subsequent choice of materials (soft clay); her interactions with the media; her movement and placement within the ETC; any emerging themes for further exploration in future sessions; as well as her levels of engagement and willingness to continue beyond the initial 15 minutes.

Two things surprised me in her choice of soft clay and her interaction with the material. Firstly, in terms of Kagin’s (now Graves-Alcorn) Media Dimension Variables (MDV) (Graves-Alcorn, 2011; Burns, 2009) she had indicated an initial interest in the more controlled, contained and resistive media such as pens, textas and collage, but had decided upon the plastic, tactile and soft clay. Perhaps this was more a reflection of her rigidness, as it was the media that was directly in front of her after we had walked around the table and looked at each of the options.

Secondly, I was surprised by how quickly she moved through different interactions with the clay – from expressing delight in the tactile softness of the clay and the way it reminded her of playing with “slime” as a child (this would become the theme of a following session); to the creation of a representational object (an Atari game controller) which led her to play out a “shooting” scenario; which in turn moved her to thoughts of playing with nephews – her brother and sister’s children; then the extended family; the love and support of her siblings and step mother; and into a sadder reflection on the recent death, approximately one year earlier, of her father to cancer. There was something powerful which was experienced in the affect which her interaction and play elicited. I also found myself experiencing elements of identification and counter-transference in the shared experience of my father undergoing treatment for cancer and my desire to empathize with and reassure Lisa.

Following on from this session, Lisa was keen to make and play with some “slime”. This was evidenced in her enthusiastic chatter over breakfast on the following day about the forthcoming session. During the session she often complained about the difficulty of the task, particularly in picking up and measuring out ingredients, but did manage with some prompting and encouragement. I saw this behavior as an indication of her years of institutionalization (having a lot of things done for her); her possible embarrassment over her tremor; the concreteness in her thought processes and just wanting to get it done; and cognitive impairment which made it difficult for her to read and maintain the series of directions involved in the slime recipe. Never-the-less, once the slime had been made she worked with it for approximately 30 minutes, continuously kneading and stretching it and recounting childhood memories of playing with slime and watching her mother knead pizza dough. Once again this experience elicited thoughts of family, their love and their support for her.

In keeping with her concrete and fixed nature Lisa nominated to terminate the session at exactly 3pm by the wall clock.

Lisa stated on many occasions that she loves to dance and sing. As a result of interactions with clients over breakfast I had initiated a time of breakfast music. Lisa nominated ABBA for her choice of breakfast entertainment and she sang and danced freely to the music. It is somewhat difficult to talk about but I felt a level of awkwardness and discomfort with some of the slightly more provocative dance moves when they were directed toward me and I wondered about Lisa’s playing out of transference issues and what would be appropriate responses professionally on my behalf. In the end I took my cue from nursing staff in the room at the time and distracted Lisa’s gaze towards others in the breakfast area. Whilst not experienced at the level described by Celenza (2010) in The guilty pleasure of erotic countertransference: Searching for radial true, I was never-the-less challenged by Lisa’s interactions and they gave rise to subsequent contemplation of this aspect of the therapeutic relationship.

My final session with Lisa sought to extend her ideas and thoughts of family. During this session Lisa created a collage and text item for herself and each member of her family (in this case she chose her siblings only) and placed them in relation to each other.

This took place in a different room than usual to avoid interruptions. It was noted that, due to her concrete and set ways of thinking, Lisa was not initially comfortable with working in a new setting but once she quickly became engaged in the art therapy session stated that it was alright to remain and continue. I hoped that the session might reveal some insight into the balance between the psychological and physiological factors contributing towards her negative schizoaffective symptoms – the developmental, family history versus whatever neuropsychiatric factors were present.

In the end it was a simple session of recognition and affirmation of family love and support, care and interaction. In moving with her directive and guidance we had touched on some joyful aspects of her present situation and the importance in one’s wellbeing of having caring and supportive relationships. She was happy with whatever placement her collaged symbols of herself and her siblings took because no matter what they would be “in the room with me, close” (Pizzato & Read, September 23, 2013).

4. My Development as an Art Therapist and Related Theoretical Understandings

In working with Carmelisa Pizzato I was stretched to continuously consider and apply my own theoretical understandings in preparing for, undertaking and journaling each art therapy session engaged in. As mentioned throughout this paper, much of what I have learnt and done within the Neuropsychiatry Unit’s setting has been based on both Roger’s and Ogden’s theoretical mores of acceptance, holding, and being (Rogers, 1957; Ogden, 2004), within the setting of working with those whose medical prognoses are that of decline, fragmentation and death.

I have also been greatly influenced by the writing of Kenneth Wright and his discussions in Mirroring and attunement: Self-realization in psychoanalysis and art (Wright, 2009), particularly those revolving around pre-verbal and non-verbal contact of the child with the mother and the place of art as transitional object and form of communication.

In addition I spent a lot of time throughout this placement considering the notion of hope in relation to the Neuropsychiatry unit’s clientele and my own development as a practicing art therapist. Whilst I strongly believe in the idea of hope as a notion for encouragement and maintaining quality of life and sense of wellbeing in the experience of one suffering from a neuropsychiatric illness, I am less convinced by the actual theory of hope as espoused by Snyder, Rand and Sigmond (Snyder, Rand, & Sigmon, 2005). Here I found hope had been categorised and forced into a formulaic structure, where hope is defined in terms of "pathways thoughts" and "agency thoughts" along a timeline of "learning history", "Pre-event" and "event sequence" (see - "Schematic of Feed-forward and Feed-back Functions Involving Agency and Pathways Directed Thoughts in Hope Theory (Snyder, Rand, & Sigmon, 2005, p. 259)").

It appears that hope theory is self-deterministic involving belief arising out of past history (successes of cause and event and correlation) and belief in self-directed agency - the self that is capable as the agent of causal chains of events. But how do I work with those who have a sense of failed hope, who past history emotionally, physically and mentally has pushed them to have no belief in the capability of their own agency (Snyder, 2002; Snyder, Rand, & Sigmon, 2005; )?

The hope theory model could equally be used as model for despair theory... where cause, event and correlation are linked to negative events and the self as agent for causal chains of negative and failed events.

In discussions with my supervisor at the Neuropsychiatry Unit, I have been led to read further in Moshe Talmon’s concept of the single session, “no-bullshit, down-to-earth form of therapy” (Talmon, 2012, p. 9; see also Green, 1998; Young & Rycroft, 1997; Young & Rycroft, 2012; Young, Weir, & Rycroft, 2012).

At first I dismissed it as an economic rationalist’s ideal form of counselling, but the more I have read about it, the more it appeals to me on many levels, particularly if I take Moshe Talmon’s own stance on the actual philosophy behind single session therapy (SST) (Talmon, 2012). In particular, in my striving to do what is best by the client, to maximize the sense of acceptance, holding and hope, I find a strong resonance with Talmon’s following statements:

Today, if I still adhere to any ideology in my practice of SST, it is probably to an ecological belief in maximizing the therapeutic effect of each session… [it is] about respecting each client;s choices, culture, and belief system. It is about being experience enough (or, if you wish, flexible enough) to leave aside therapy by the book, by the protocol, or by the theory. It is about allowing yourself again and again to know that you don’t know, so you can be surprised and learn something new from every new client and every first session.(2012, p. 9)

Finally, one of my big areas of growth as an art therapist, particularly within a setting such as the Neuropsychiatry Unit, is to value the use of art therapy as a purposeful form of diversion therapy. In particular, the discussion offered by Kravits (Kravits, 2008, pp. 111-127) in Chapter 6 of Art therapy and clinical neuroscience (Hass-Cohen & Carr, 2008) gives strong weight to the argument for the use of art therapy as a diversion based intervention in terms of reducing stress, anxiety and related somatic symptoms arising from the responses to stress and anxiety of the Hypothalamic – Pituitary – Adrenal (HPA) axis cycle (Kravits, 2008, pp. 111-127; see also "The HPA axis in health and disease," 2011). This is particularly salient for clients admitted to the Neuropsychiatry Unit as they are often experiencing fragmentation and confusion and also have to deal with the fear and uncertainty of diagnostic investigations for what are usually devastating neuropsychiatric illnesses.

Lisa’s Epilogue

After 6 weeks, the results of the blood tests were returned with a negative indication for deletion 22q11 (VCFS). In an interesting twist, however, it was discovered that she has a rare deletion of the filamen-A protein. Previously, in 2006, she had been tested for a mutation of the filamen-A protein but the fact that it was actually deleted had not shown up in the test since the test only looked for a mutation. This new finding will assist in informing future treatment and care for Lisa.


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