Back to Top

Case Study: "Carmelisa Pizzato - Notes and Transcripts"

Carmelisa Pizzato -
Carmelisa Pizzato - "More Slime"
Carmelisa Pizzato - "More Slime"

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


Clozapine 300mg nocte
Valproate 500mg bd
Aripiprazole 7.5mg nocte
Benztropine 1mg bd
Hx schizoaffective disorder. First dx at 29. first admission 2004. 2006 attempt suicide - medication overdose. Predominantly negative Schzaff symptoms.
In Nψ to check for possibility of VCFS (deletion 22q11) which is a possible diagnosis for "cocktail" of symptoms.
Epilepsy - controlled by medication
Previous neurological illness was felt to be consistent with X-linked nodular periventricular heterotopia caused by a filamin-A mutation which results in aberrant neuronal migration associated with epilepsy, an idiopathic thrombocytopenia, and cardiac valvular/aortic root dilatations.
Admission to help her team manage worsening tremor in her upper limbs.
  • How do I bind together the theoretical frameworks of person centred; humanistic, existentialism; mindfulness; focusing oriented; hope based; acceptance commitment therapy???? Particularly with a client base which may lack insight and capacity; is facing loss of function - physically, cognitively and psychologically; and in most cases will continue to fatally deteriorate prematurely????
  • Is depth of interaction and meaning always a necessary factor in the therapeutic encounter?
  • Are purpose, objective, outcomes, aims essential to an art therapy interaction?
  • How does one evaluate the value of a non-directive, seemingly unpurposeful art therapy interaction?
  • If a client is happy to work on a "superficial" level is there any need to go beyond? How does one evaluate whether or not a need to go beyond is necessary?
  • Is there a place for hope in existentialism...? - Actually, what does hope mean in the context of existentialism? Is hope in direct opposition to despair? Is hope theory too closely related to CBT in terms of reframing cognition and beliefs; concerning future states and events; and expecting "happiness" to follow on from event control and self empowered agency?
  • 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 as the agent of causal chains of events. 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 in causal chains of failed events. However - I would like to work within a model of hope which is different. Rather than hope being related to events, hope should be related to assurance that in the midst of despair there is always potential for experience of joy??????????

From Kierkegaard


Despair has several specific levels that a person can find themselves, each one further in despair than the last as laid out in The Sickness Unto Death.

The first level is "The despair that is ignorant of being despair or the despairing ignorance of having a self and an eternal self." Essentially this level is one which has the wrong conception of what a self is, i.e., is ignorant of how to realize the self one already potentially is. In this sense, the person does not recognize his own despair because he often measures the success of his life based on whether he himself judges himself to be happy. Regardless of whether you know you are in despair or not, Kierkegaard asserts, you can still be in that state. He notes that this is the most common in the world.

The next level of despair is "The despair that is conscious of being despair and therefore is conscious of having a self in which there is something eternal and then either in despair does not will to be itself or in despair wills to be itself." The first form of this conscious despair is "In despair not to will or want to be oneself." This becomes further subdivided into three categories: the one already mentioned, the despair not to will to be a self, and lowest, the despair to wish for a new self. These three divisions are mostly the self-worth the person has and the amount to which they understand their own despair. The despair to not be oneself is pretty straightforward. A person sees themself as unworthy and as such does not see themself as worthy before something they do not understand. The despair not to be a self is deeper, because to not wish to be a self is to wish to not have a relation to God or at the very least see one's relation to God as unworthy, and thus shrink from it. The lowest form of this group, however, is the desire to be a new self. This is logically the deepest form as it assumes the deepest understanding of one's despair. Once in despair, without a complete relation to God one will always be in despair, so to be in this level one understands the permanence of the despair. The despair in this group arises from the nature of sensate things and physical desires. These three sub groups are also grouped under the heading "Despair over the earthly."

The second level of conscious despair under the heading "Despair over the eternal." Someone in this level views themself in light of their own weakness.
Unlike in the upper level, this weakness is understood and as such, instead of turning to faith and humbling oneself before God, they despair in their own weakness and unworthiness. In this sense, they despair over the eternal and refuse to be comforted by the light of God.
The last and lowest form of despair is the desire "In despair to will to be oneself." This last form of despair is also referred to by Kierkegaard as "demonic despair" (Note that the term demonic is used in the Classical Greek Sense, not the modern sense). In this form of despair, the individual finds him or herself in despair, understands they are in despair, seeks some way to alleviate it, and yet no help is forthcoming. As a result, the self becomes hardened against any form of help and "Even if God in heaven and all the angels offered him aid, he would not want it." At this level of despair the individual revels in their own despair and sees their own pain as lifting them up above the base nature of other humans who do not find themselves in this state. This is the least common form of despair and Kierkegaard claims it is mostly found in true poets. This despair can also be called the despair of defiance, as it is the despair that strikes out against all that is eternal. One last note is that as one travels further down the forms of despair, the number of people in each group becomes fewer.

Read more: http://www.answers.com/topic/philosophy-of-s-renkierkegaard#ixzz2fsM6g68D

(Lisa)

Most people don't notice, but since I've slowly lost a lot of weight over the last few years, my face looks a bit longer and more like a triangle pointing down this way... and if I smile real big, with big wide eyes, people don't think too much about it - they're just happy... Besides - with my croaky voice and being a bit slow with reading and talking, you know, like, I think they think I'm a bit simple, so I be happy and they be happy and they like me... 'specially since I be a bit cheeky sometimes and give 'em a bit of shit-stirring...
LIKE - Hey! Did you just call me Carmelisa! Don't ever call me Carmelisa... It's LISA! Lisa Pizzato. I don't like that Carmelisa stuff! You should never call me Carmelisa. Ha! Ha! But seriously - Lisa only!
My family's got some good genes - from my mum... all my sisters and my brother - we all look young for our age. When people find out I'm already 45 they always ask how come I look so young... I just tell 'em I use lots of Ponds cream, but I think it's from my mum. That's my real mum - not my step mum, who I call mum now and who's beautiful too and looked after me growing up - but my real mum. She died when I was just about 1 or 2 from something in her brain, but I've seen pictures and she was gorgeous and young looking.

(Neuropsychiatrist)

Next we have Carmelisa Pizzato, a 45 year old woman. 3rd in sibship of 4 - older brother and sister; younger step sister. Mother died approximately year and a half after she was born - been raised by step mother since about 3 years old. Father died about 2 years ago. Reports good support from step-mother and siblings.
History of schizoaffective disorder. First diagnosed at 29. Hospitalised in 2004. In 2006 Carmelisa attempted suicide - medication overdose. Subsequently came here for further investigation. Displays predominantly negative schizoaffective symptoms.
Current medication:

Clozapine 300mg nocte
Valproate 500mg bd
Aripiprazole 7.5mg nocte
Benztropine 1mg bd

Epilepsy - controlled by medication
Previous neurological illness was felt to be consistent with X-linked nodular periventricular heterotopia caused by a filamin-A mutation which results in aberrant neuronal migration associated with epilepsy, an idiopathic thrombocytopenia, and cardiac valvular/aortic root dilatations.
Primary reason for this referral / admission is to help her management team with ways to manage worsening tremor in her upper limbs.While she's here we'll get a full workup - O.T.; neuropsychology; bloods; speech to check on her swallowing; imaging - MRI; SPECT; EEG; ECG; physio; etc.
I also think we should definitely check for possibility of VCFS (deletion 22q11) - likely diagnosis for her "cocktail" of symptoms. Surprising it wasn't looked into during her previous admission here, but then again, it's a much easier test now than then - we'll send off some bloods. It should take 5 to 6 weeks. I'd put my house on it being VCFS, though.




(Journal)


Journal Entry, Monday September 16:


I met with Carmelisa for the first time today, but I had already decided that I would most likely ask her to work with me as my case study. She had been introduced during ward rounds and discussion had focused the opportunity to screen for a genetic disorder known as Velo-Cardio-Facial Syndrome (VCFS for short) or "deletion 22q11" during this admission. She had been in the unit previously in 2006 and they were surprised that with her combination of conditions - aortic dilation; slight psychosis; low / borderline IQ; slight facial asymmetry - she hadn't been checked then for VCFS. But then again VCFS can manifest in a number of seemingly unrelated symptoms from cleft palette to auto-immune issues to psychosis and has historically run the risk of being misdiagnosed or diagnosed as one or another of a range of syndromes or conditions. It is only more recently with the advent of genetic testing that it has been discovered that the one common factor is a deletion occurring in chromosome 22 in a location designated as "q11.2".
I really wanted to work with Carmelisa because, previously, in my placement at a SECU, I had worked with a woman who had deletion 22q11, who was suffering extremely from audio (and probably visual) hallucinations to the extent where she would rarely appear to be aware of the real and present world, constantly distracted by and chattering with those in her own bubble of existence. Carmelisa's symptoms were mild by comparison and I relished the opportunity to work with someone who could help in reframing my cognitive and emotional conceptions of the syndrome.
I spent most of the hour or so I spent with her this morning just chatting to get to know her and explaining my role on the unit as an Art Therapist. Lisa (as she definitely prefers to be called) is a friendly and chatty person, who has a cheeky and playful nature. I explained about the case study and she agreed to participate. We organised a session for later in the day. I plan to get a feel for where she is at with regards to the different components of the Expressive Therapies Continuum.





(Lisa)

Hey, Colin! Yeah! - I get to do some stuff with you again. It's 2 o'clock now and we can go till 2:30 when my sister, Mary, will come... we can go till then. What do you want me to do? - there's so many things here - all this stuff you got set out on the table tennis table. I like this room, I'll sit here. OK - yeah - clay... colour pencils... I don't like paint - how it gets everywhere... mandalas? - oh those circle things yep... these textas look good - I might use them... and collage stuff - I could cut some or use them and glue them on the paper over there... water paints - no don't like the paint stuff... no - I don't want to make a hand if I have to try to keep my hand still for a while... some toys - like kids toys... hmmm...
No - I think I'll just stay in my seat here and use this soft clay stuff. What do I have to make? Anything I like? OK! Yeah!....
Ooohhh! I love the feel of this stuff - it's beeeaautiful! It feels so soft and smoooooth! Gooorrrgeous! It reminds me of that green stuff we used to play with when I was a kid - I used to love that stuff! Yeah, what was it called? Oh, yeah - slime... That stuff was fun! Yeah, we can make it? I'd love to do that, Colin...
Look what I made out of the clay - I made a Atari game thing. Pshew! Pshew! I play this with my brother and sisters' kids - my nephews... Pshew! Pshew!
Yeah - my brother and my sisters and my mum - they all really love me and take good care of me. Pshew! Pshew! They visit and take me out for coffee and stuff like that... They're soooo good to me... Pshew!... She's my step mum but I call her mum... and dad died from cancer just a couple of years ago. That was so sad, Colin... cancer is no good... he loved me too...
It's 2:30... I think Mary's here now... I'll squash it away and we got to stop...



(Journal)


Journal Entry, Monday September 16 (later):


Thinking through the session with Lisa earlier today I am struck by a few things:

  • how definite she was about not using paints or anything too liquidy - perhaps this is a reflection of her concreteness and rigidness. I also got a hint of this in the way she didn't want to move from the seat she had chosen and also how she stuck to the 2:30 finish, even though Mary was happy to wait if Lisa wanted to continue
  • how reactive she was to the soft clay, the affect she displayed and how she expressed her pleasure in its texture and the tactile experience
  • how quickly she moved from talking about her family in a matter of fact manner to "teariness" about their love for her. More affect experienced in the memories of family interactions and support she experiences.


I have promised Lisa we will make some Flubber during the next session, and she is quite keen to do this. Hopefully this will be another opportunity to explore her sensory and affective responses and to see where the conversation leads. Perhaps even some kinaesthetic action with the Flubber. Using the simple Flubber recipe should also aid in feedback to the team as to her reading and comprehension skills at least on a fairly basic level.
I was a bit annoyed working in the multipurpose room and having people coming in and interrupting a couple of times during the session. Will have to find a spare consulting room next time. Would like to do a kind of family based sociogram using collage. Might be an opportunity to feel out whether or not Lisa wants to talk more deeply about her family - her real mum and her father.
It hit me a bit talking today about her dad and his death to cancer. I note in her case file it was liver cancer, so I got a bit of stuff going on with relation to my own dad at the moment. I suppose the best I can continue to do is to be congruent and open and be willing to be transparent, but I also need to balance my needs against hers... Maybe that's something I can bring up in supervision...





(OT/Welfare)

Well, Lisa's a bit of a darling... She's come from a community residential service for homeless women. They're right to take her back when she gets discharged from here. She's got good family support with regular visits - mainly from her step sister, Mary.
On the other side of things - she did a cooking task with the OT and was a bit disorganised. She had to read the recipe often and often lost track of where she was up to, getting the sequence wrong a couple of times. They ended up ditching the recipe and settling for toast and a cuppa which she did ok, but with prompting.
She appears to be quite institutionalised and asks for help with a lot of simple things such as cutting her toast or opening the jam packets.
She doesn't have any guardian or designated full-time carer, so she is currently making her own decisions and is deemed to have capacity although this will probably need looking into as she progresses.
The arm tremor has reduced since the change in her medication, but she still appears to be self conscious about it... for example when she eats her porridge at the breakfast table she holds the spoon in the hand that has the tremor and holds THAT hand with her other hand in order to reduce the effect of the tremor. All in all she's doing well on the ward and everyone - nursing staff... the other patients... the cleaners - they all think she's lovely.




(Journal)


Journal Entry, Tuesday September 17:


Spoke with Lisa over breakfast on the unit - well, she actually spoke with me. As I entered the unit she started talking about the slime we are planning to make today. She was very animated and excited by the prospect and joked about sliming some of the nurses. We also talked about favourite things and Lisa expressed how much she liked singing and dancing and her favourite band was ABBA.
The famous Flubber session started at 2pm and, in keeping with Lisa's sense of concreteness, she purposefully stated that we would need to finish at 3pm. I knew she would keep to this with some rigidity.
The first 15 minutes of the session was spent in discussing and signing the permission and release forms. Lisa was very specific that she was happy to have photos and video taken providing neither her face or her voice were recognisable in any of the material used.
We work on recipe for "Flubber": Lisa was able to read it read OK but needed to constantly check and recheck as we went through the process. For example, she sometimes required prompting to recheck quantities read within previous minute or so.
In keeping with the kind of institutionalised behaviour she expressed difficulty mixing and pouring - stated this was due to tremor but proved to be OK with encouragement and not as bad as she predicted. Lisa claimed to be too weak and that things were too heavy when asked to lift and pour a cupful of PVA glue. She gave a go but continued to complain, in the end asking me to do it for her as it was "too heavy".
When it came to the crunch of playing with the slime Lisa requested gloves to handle it stating that she didn't want to get "green" on her hands.
In terms of Lisa's response to working with the actual slime she loved playing with it and especially kneading it... she kneaded the slime for about 20 to 30 minutes whilst talking often about related topics of watching mother knead pizza dough and playing with slime as child.
She regularly commented on how relaxing activity was.
At exactly 3pm by the wall clock she nominated to terminate the session...





("Dancing Queen")

Lisa Dances and Sings
I talk about the joy of breakfast music sessions, whilst Lisa's does some "sexy dance moves", and later I ponder the introspective nature of playing "somewhere over rainbow" on ukelele

(Lisa)

Yeah - I had a good weekend. Mary visited and I watched TV with the others...
How come we're going to a different room - I really liked the room we were in the other day. I'd really like to work in the other room from the other day... Yeah - I suppose there were a couple of interruptions and it'll be ok... if I don't like it after a couple of minutes we can go back to the other room. Yeah... that's OK...
Now you're making me do all this hard work...
I want to work here, I can't work by the window we're too high up and the view scares me... You're a toughie, you know, but I love working with you and I haven't seen you for a couple of days...
I'll do me first, cause I love dancing and singing and this lady is in pink like how I like pretty pink things...
That's a bit hard to pick my favourite person from my friends and family, because my brother and my two sisters look after me really well and they love me a lot so I haven't really got a favourite... yeah, I rather put them all Antonina, Mary, Franco.
Hmm... looking at these collage bits - this a flower... flower... pretty... Antonina is I like this one... I'll put Antonina is pretty as a flower...
This is tough doing it... just choosing what's resembles... um it's like giving it a bit of a go to think what are their symbols...
Mary... this is pretty tough... I should have only chosen one...
Hmmm... Mary has lots of love...
geez... you're getting me to do some tough projects... how am I doing? It really makes you think... It's good... yeah... good... happy... teary and smiley...
Franco... geez... there's so many... um... I'll do this! Franco loves his lattes
And if we were all in this room together we'll all sit around this table - it doesn't matter the order... doesn't matter as as they'll be in the room with me close yeah...
And now ... We get to go for walks up to the coffee shop... we get to go up for walks we get to go out three times a week the support is so much better with my parents and brother and sisters...
Yeah... well it was epsilepsy and they were just trying new medication on me but it was too strong and so that's why they put me in CCU and then when they said the place I'm at now got a better support and a spare room... and I can stay there as long as I like and I don't have to have the doors locked... so, yeah yeah well I can just going out and socialising cause I love that a lot going out with my girlfriend yeah family as well I've got another girlfriend as well that lives there yeah and with my family yeah they come and see me they come and invite me over for lunch or dinner we go out for coffees my favourite thing yeah is the going out yeah just happy to just roll on oh that's pretty much it and that's all and it's 3 o'clock now so we better go cause Mary will be here...




(Journal)


Journal Entry, Monday September 23:


It's interesting working with someone who is fairly concrete in their thinking and has difficulty shifting to adapt. Lisa was quite annoyed that we were going to be working in a different room and only ended up agreeing to it once I assured her that it meant we wouldn't be interrupted and also that she could choose to go back to the previous days' room if she was still not happy after trying the new room. It was good that she obviously got into the collage family exercise enough to be happy to stay in the room.
It was good to explore her family relationship and it's fantastic to see how loved and supported she feels. Still, I do wonder how much of her developmental history in terms of her mother dying when Lisa was only a baby and her being raised by her step-mother plays a part in her past episodes of negative schizoaffective disorders and how much is attributable to the 22q11 deletion syndrome. What's the balance between the psychological and the physiological?
I'm finding the more I do this, the more questions I have and the more I struggle with finding my footing in terms of my theoretical stance and clinical practice...
I kind of wish there was an evidence based, person centred, humanistic, hope based, existentialism, with integrated elements of mindfulness, focussing oriented art therapy, play, humour, acceptance commitment therapy, and without too much weight on the CBT side of things.
Looking at some of the information about hope theory, I've been disappointed that it's 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".
And your Traits and States of hope can be rated on the various "hope scales".
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?
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 failed events.
So this is not the model for hope theory that is for me. I would like to work within a model of hope which is different. Rather than hope being related to events, hope should be related to assurance that in the midst of despair there is always potential for experience of joy, or at the least,ability to not be overwhelmed by the despair.
For me Acceptance and Commitment Therapy holds a lot of these elements, but I still have trouble personally with the CBT aspects of ACT. particularly when dealing with those with neuropsychiatric illnesses such as Lisa's, where the willingness or ability to think cognitively about behaviours is often clouded by complex psychosocial biological conditions.
Lisa belongs to a client base which may lack insight and capacity; is facing loss of function - physically, cognitively and psychologically; and in most cases will continue to fatally deteriorate prematurely.
With this in mind, are there times when offering hope is dishonest in the face of the prognostic outlook?
Does a patient hear the truth or hold to the hope, despite the reality...?
Is it always necessary to seek a purpose, objectives, outcomes, in an art therapy interaction?
How does one evaluate the value of a non-directive, seemingly unpurposeful art therapy interaction?
If a client is happy to work on what appears to me to be a "superficial" level am I obliged to dig deeper? How does one evaluate whether or not a need to go beyond is necessary? Is there opportunity for the needs of the client to be met?
For me it still pretty much comes back down to what Ogden has said of the mother child relationship and that we allow a place for the client to "go on being"...





Hope
Joy
Laughter
Unconditional acceptance
Love
Support
Value
Compassion
Holding
Containment
Safety
"Going on Being"