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Case Study: Ajana Nirnayera - "Without Memory, There is no Guilt; Without Decisions, There are no Mistakes"

Ajana -
Ajana - "PicCollage"
Ajana - "PicCollage"

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






This is a case study of Art Therapy interventions undertaken by the writer with a female inpatient in a major Australian hospital's Neuropsychiatric Unit. The patient was undergoing diagnostic testing to establish a possible cause for rapid loss of some physical and, more specifically, cognitive functioning, including major memory loss and amnestic disorder. This loss of functioning had noticeably progressed during the twelve months prior to her admission. This paper explores engagement, assessment and treatment undertaken with the patient, from the writer's own Art Therapy perspective at this stage in the writer's career and professional journey. As such, the writer's own current Art Therapy theoretical stance is also presented within the context of the case study and the subject involved.

Keywords: case study, amnestic disorder, art therapy, major depressive disorder with amnestic features, neuropsychiatry, neuropsychology, memory loss, short term memory




Without Memory, There is no Guilt; Without Decisions, There are no Mistakes


Case Study - Ajana Nirnayera


Much of who we are - how we perceive our "self"; how we react physically and emotionally to everyday encounters and situations; and the decisions we make regarding small mundane matters or life changing events - is bound within and informed by the framework of our memory. In particular, this applies to our long term memory systems, especially autobiographical - episodic memory, which deals with recall of our past events (Seligman & Kirmayer, 2008; Staniloiu, Markowitsch, & Brand, 2010). Our ability to lay down and recall autobiographical events and their temporal placement - whether 2 minutes, 2 years or 2 decades - enables us to perceive our self within the context of history and being.

"We were there, it was then and we did that - for better or for worse".

Here, the author requests that you do something a little different than usual in the reading of a paper or article. Go and take a break for a few minutes - make yourself a cup of tea or coffee; have a snack; read the news headlines; check your Facebook account - then come back to this paper. It is OK - I will wait.


Figure 1 - The five long-term memory systems and their assumed brain bases (Staniloiu, Markowitsch, & Brand, 2010, p. 781)





Good, you are back.

But, how did you know to come back? Why did you not simply move on to and remain in whatever new activity you had picked up on? When you returned, how did you know where to recommence the reading from?

Now... a little thought experiment: if you had impaired memory capability, and were unable to readily recall newly laid down events such as reading this paper, would you have returned? Or, if you had returned would you ever get beyond the first couple of paragraphs or get stuck in a loop of following the instruction to take a break and return, each time forgetting that you had already read the first two paragraphs?

In many ways, this is the world of Ajana Nirnayera, the subject of this case study. The writer encountered Ajana in the Neurospychiatric Unit of a major hospital located in one of Australia's capital cities.

The purpose of this case study is to document that encounter and discuss the development of processes undertaken, theoretical frameworks in support of those processes, the timeline of events undertaken and client progress in the light of those encounters. The writer will also present thoughts and insights into his own professional growth as an Art Therapist, derived from these interactions.



Demographic of the Case Study Subject

Born in Australia in 1975 into a reasonably functional South Eastern European immigrant family, Ajana was a 38 year old woman when first encountered by the author in 2013.

Ajana is the third of three siblings, having an older sister and an older brother. Her parents remained together throughout their entire married life until the death of her father in his early eighties. Her father was reported to have been diagnosed with Alzheimer's Disease in his late seventies, and remained bedridden during the latter years of his life. Ajana attended and completed year 12 high school with average grades, and entered the workforce without continuing on to tertiary education, preferring to undertake work in the retail sector.

In 2001, Ajana married her current husband, Sbami, and in 2004 they had their first child, a girl, now aged 9 years. With reference to Ajana's genogram (see Figure 2) it is noted that her mother currently lives with Ajana and her husband. As such, her mother takes a primary role in the care of their daughter, Kanya.

Figure 2 - Genogram: Ajana Nirnayera


A closer look at the genogram hints at further issues. The relationship between Ajana and her husband, Sbami is highly fused - they are very codependent, inward and insular in their interactions, and this is highly evident when in the presence of others.

It can also be seen from the genogram that their 9 year old daughter is considered with some indifference and apathy by the father. Kanya, their daughter, has been diagnosed as having a genetic disorder with Autism. The abnormal gene causing this is known to be carried by the father. It has been admitted that the knowledge of this is a contributing factor to his distancing himself from her.

In the beginning of 2012 a second child of unreported gender was diagnosed in utero with the same genetic disorder.

In February of 2012 the decision was made to terminate the pregnancy, but because of cultural and religious beliefs, the loss was reported to family as a miscarriage.

Because of Sbami's (the father's) indifference and Ajana's current presenting issues, which will be discussed in more detail below, care for their special needs daughter has been poor at times. Consequently Ajana's mother, Ma Tara, has moved into their home as the primary carer for Kanya. This has caused some conflict between Ajana and her older siblings, particularly her older brother, as well as between Ajana and her mother.

Both her older brother, Bha'i, and her mother believe Ajana's symptoms are being "put on" and are often very vocal in their demands placed upon her to "snap out of it".


Presenting Issues and Client's General Level of Functioning

Ajana was referred to the Neuropsychiatry Unit by a private psychiatrist to whom she had originally been referred by her GP. This had been in response to a range of issues arising in the twelve months prior to her admission in early 2013.

During this period Ajana's weight had dropped by 20 kilograms and her cognitive and executive functioning had declined significantly and rapidly. She had become increasingly isolated and withdrawn, and displayed the symptoms of a major amnestic disorder with the possibility of psychosis and catatonia. When questioned by friends and family about events and associated circumstances, she would invariably reply, "I don't know" or "I don't remember". Whilst compliant and agreeable in manner she became increasingly inactive and noncommunicative, lacking in initiative and motivation.

The purpose of her admission to the Neuropsychiatry Unit was primarily diagnostic in order to determine the most likely cause of her presenting issues. This entailed a range of psychological and physiological tests and interviews, including neurological imaging; cognitive functioning; psychological assessments; welfare and family dynamic assessments; occupational therapy and related levels of functioning; and gathering of collateral medical and social history.

The author worked with Ajana from within this context in the capacity of a Master of Art Therapy student on placement in the Neuropsychiatry Unit, as a part of the Allied Health Services arm of the diagnostic team. In addition to providing adjunctive and supporting diagnostic evidence, one of the functions of the Allied Health Team within such a heavily weighted medical structure is to help in representing the person behind the diagnosis (R. Dewhurst, Personal communication, May 2, 2013).

In terms of the diagnostic axes of the DSM-IV-TR (Diagnostic and statistical manual of mental disorders: DSM-IV-TR., 2000) the following set of differential diagnoses was presented at Ajana's admission:

Axis I - Primary Psychiatric Diagnosis

(i) Amnestic / neurodegenerative disorder for investigation with possible diagnosis of schizophrenia

(ii) Major depressive disorder with psychotic features

(iii) Organic psychotic disorder

Axis II - Intellect and Personality

(i) Deferred

Axis III - Physical Health

(i) Loss of weight

Axis IV - Psychosocial Stressors

(i) Family conflict following recent deterioration in patient's function

(ii) Recent conflict with neighbours (iii) Ongoing care needs for disabled child

Axis V - Level of Function

(i) GAF = 11-20 (intermittent inability to care for self OR grossly impaired communication)

It is to be noted that "Axis IV - Psychosocial Stressors, (ii) Recent conflict with neighbours" refers to another example of major behavioural changes in Ajana, which have also added weight to the psychotic aspects listed in Axis I.

Prior to the onset and development of symptoms throughout 2012, Ajana had been active within her community. She had worked with some enthusiasm to put together a petition and canvas local residents in protesting against the commercial development of the property adjoining her own. The petition was unsuccessful and subsequently Ajana had developed some paranoid and delusional behaviour, believing that the neighbours were shifting the fence dividing their two properties in order to gain extra ground for the development. It was Ajana's belief that this was being done covertly and incrementally during the nighttime. Consequently, she would remain awake throughout the night in order to "keep guard". Ajana also convinced Sbami (her husband) to mark in the fence line and install security cameras to document and monitor any shifting of the fence which may occur.


Theoretical Framework and Clinical Reasoning

When considering the theoretical framework informing the writer's development of interventions with Ajana, the writer was particularly struck by a poem entitled "Ringing the Bells" by Anne Sexton (Sexton, 1981, pp. 28-29; see also Appendix A) which resonated very much with observations of the experience of Neuropsychiatry Unit patients. In particular, it was the final few lines of the poem - "...and although we are not better for it, they tell you to go. And you do." (Sexton, 1981, p. 29) - which connected most. These words were very indicative of the patient's experience of disempowerment within the ongoing diagnostic regime of the unit, often with no specific diagnosis being reached.

In addition to the diagnostic regime, Ajana's level of amnestic disorder meant that she was, in effect, living much of her life through the window of each moment with very little sense of newly created history or future momentum. As Winnicott has said, she was simply "going on being" (as cited in Ogden, 2004, p. 1350). As such the author sought primarily to base all the art therapy interventions on the premise of providing a sense of holding and a safe place of 'being'.

Secondly, and of equal importance, the author is convinced that the success of the therapeutic process is dependent on establishing congruence, unconditional positive regard and accurate empathetic understanding in a trust-based therapeutic relationship (Rogers, 1957). The author's practice is very heavily grounded on the theoretical framework of the person centred therapeutic relationship. Bound into this and related to the previous points, the writer believes that issues which confront us daily are manifestations of our existential state of being. Bringing this into the Art Therapy context there is a constant need to be aware of how the creative process often gives light to the driving impact of the givens of existence within the lives of the client - death; freedom; isolation; meaninglessness; and embodiedness (Cooper, 2003; Moon, 2009). It is the place of the art therapist to allow these issues to be confronted and explored, with frankness and honesty, assisted by the revelations which may be inherent in the created object.

Further to this, the awareness of Ajana's amnestic disorder and a sense of fragility in her situation drove the writer to offer art therapy engagements which were invitational and inclusive of the "option to opt out". This was also in order to avoid the imposition and stress by association which would be involved in making the art therapy encounter mandatory as were the medical tests and procedures she was required to undertake. In this way art therapy was introduced to Ajana as an alternative to all the compulsory activities of her hospitalisation.

Other key criteria of the art therapy activities sought to be introduced by the author were that they be open ended, but held within set parameters. This allowed for exploration and play, whilst minimising the possibility of her being overwhelmed by such things as too much choice in materials and media, or too great a range of thematic options presented. In addition whatever was offered needed to inherently have the possibility of attaining an outcome - that is, it had to be achievable for Ajana.


Sessions Undertaken and Changes Observed

There were five art therapy sessions undertaken by the author with Ajana. The initial sessions were designed to "break the ice" and establish a trust-based relationship between the author and Ajana. Although there was no reason to believe that Ajana would remember the author or any associated art therapy encounter from one session to the next, it was believed that a sense of wellbeing, trust and safety could, at the very least, be established on an unconscious level. Additionally, the nature of the Neuropsychiatry Unit's diagnostic testing in conjunction with other services within the hospital meant that the author needed to take opportunity of "ad hoc" based encounters rather than rely on scheduling sessions for specific times.

The five sessions are detailed below with discussion of Ajana's interactions, responses and changes as observed by the author.

Session 1 - "Breaking the Ice", part 1: Neutrino
Monday, March 4, 2013

This session was an opportunistic encounter in which the author sought to understand how engaged in an activity Ajana might be capable of. In order to avoid being over-demanding, the author decided to not require any actual art work from Ajana, but rather offer her some playful auditory and visual stimulus using the iPad app, Neutrino. Neutrino is an app which responds to the users touch with shapes and sounds. Different gestures on the iPad screen produce different visual patterns and alter dynamic, range, pitch, etc., of sounds created (see Figure 3 for a screen grab taken from the iPad app, Neutrino).

Figure 3 - Screen grab from iPad app, Neutrino MASTER OF ART THERAPY, 2013: CASE STUDY 13


After giving Ajana a short demonstration of how to interact with Neutrino, she was invited to take the iPad and "play" with the app. She responded by accepting the iPad and proceeded to play with the app for approximately five minutes. The author noted that whenever she was asked how she might reproduce certain pitches or visual patterns she responded with the usual, "I don't know how" or "I don't remember how to do that" and her level of interaction with the app would diminish.

After approximately ten minutes Ajana was required to have her blood pressure taken and she did not choose or remember to return to the activity after this interruption. This was despite the fact that the author remained in her vicinity and in contact for a few minutes following, in order to judge her ability to renew focus towards the activity.

Session 2 - "Breaking the Ice", part 2: Songs and Lyrics
Tuesday, March 12, 2013

In response to the relative success of using audio in the previous session, the writer planned another session based on a musical interaction. Having found out that one of the musicians Ajana had liked in her past was Cat Stevens, the author took advantage of this next session to work with Ajana in listening to and discussing the lyrics of some of Cat Steven's songs. It soon became apparent, however, that the activity was beyond Ajana's point of readiness at the time the session was undertaken. Although she had stated that she remembered and liked Cat Steven's music, when prompted to nominate a specific song to listen to she said she couldn't remember any. Perhaps, erroneously, because it had been a much liked song of the authors, the song "Father and Son" was suggested by the author and accepted by Ajana with a dispassionate shrug of her shoulders. After listening to the song the author attempted to engage Ajana in conversation based on some of the themes contained in the lyrics. In each instant, Ajana responded to questions and cues about the lyrics with her usual answers, occasionally adding a response of "That's nice" when the themes were explained by the author. The session was discontinued after a short while when Ajana's attention was interrupted by the arrival of her husband.

The writer believes that this exercise was too abstract in it's requirement for Ajana to discuss themes presented verbally in the lyrics of the song, particularly without any reference to a lyric sheet. It was also recognised that the song chosen was not necessarily one that Ajana had any investment in from within the context of her own personal history, either experientially or lyrically. The writer decided that something more concrete in form and outcome may be required in the following sessions.

Session 3 - "Where are you at?", part 1: iPad PicCollage
Monday, March 18, 2013

In trying to find a locus from which to work with Ajana, the author felt the need to provide an art therapy intervention which, in contrast to the previous session, offered a concreted outcome. It was also hoped to determine some sense of identification and recognition between the content of the activity and Ajana's involvement in the activity. The author decided to explore the process of collage, but was aware that there were some safety concerns expressed by the unit staff with the use of scissors in the presence of some of the co-patients present on the unit at the time. There was also a lack of resources in terms of magazines, postcards, etc. which could be used for the activity. Since Ajana had shown some aptitude in the use of the iPad, the author created an extensive library of photographic images for use in art therapy sessions in conjunction with the iPad app PicCollage.

Although there were instances of prompting, Ajana was able to create an "ecollage" (see Figure 4) using such skills as selecting images, resizing, rotating and basic layering. During the process, aspects of images selected were discussed. In particular, Ajana talked about the family image, imagining that it may have been a family christmas gathering and that the bearded man may have been Father Christmas. This was said with a smile and was the first indication that the author noted of some humour in Ajana's interactions. At this stage the text had not been added. Upon returning from a short tea break, Ajana was pleased to see the collage and asked who had done it. She appeared mildly surprised, but displayed no indication of distress, when told that she had created the collage. The session was concluded by inviting Ajana to make up a title for the collage. Ajana asked the author to complete the title as she was unsure of spelling. The author attempted to engage Ajana in further conversation concerning the content of the collage based on her title, but Ajana did not wish to continue. The session was concluded in response to Ajana's request.


Figure 4 - PicCollage, "Family, Patterns, Trees"


Session 4 - "Where are you at?", part 2: Zentangle
Tuesday, March 19, 2013

This fourth session was held on the following day. At this stage the author was struggling with an internally perceived expectation that, in keeping with the primarily diagnostic atmosphere of the unit, there should be at least one art therapy interaction that involved some form of assessment. It was hoped by the author that an activity could be undertaken which could potentially be delivered at the unit ward round and concretely support various aspects of Ajana's diagnostic picture which was being developed. In order to do this the author took an art therapy tool, Zentangle (Roberts & Thomas, 2005), and used it to form a basic evaluation illustrative of Ajana's cognitive, interpretive, executive and focusing abilities. The activity involved following very specific instructions in a set order and staying on task in a focused manner.

Ajana's process of working with the Zentangle displayed an ability to understand, but not retain, instructions. Each time a series of instructions was given she was able to complete the first step of the instructions, but then required further prompting and repeated instruction to continue to the next step. One of the central apsects of doing a Zentangle is to experience the "Zen" of the process and relax, focusing on the repetitive nature of what is being drawn whilst being "held" within the confines of the Zentangle card and the areas created within its drawn boundaries. Ajana did not "connect" with these aspects of the process, stating that she did not wish to continue once she had completed filling one of the areas created on the Zentangle card (see Figure 5).

Figure 5 - Ajana's Zentangle


Whilst this may be interpreted to be a lack of focus and staying on task, it may also simply be that Ajana found the activity boring, particularly in the light of her stated inability (or perhaps lack of desire) to engage with the process on a contemplative level.

Session 5 - "Let's play!", Paper MagiClay
Monday, March 25, 2013

Looking back during the week on the previous session the author was concerned that he had been too bent on pleasing the unit team with a diagnostic type of outcome rather than remaining client focused in keeping with the person centred nature of author's theoretical working criteria. Also, reviewing the earlier PicCollage session (see Session 3 above) the author was struck with the glimpses of playfulness and humour displayed in some of Ajana's responses to the family photo and the "Father Christmas" persona she had attributed to the bearded gentleman in the photograph.

In keeping with the need to maintain an open-ended aspect to the sessions' interactions the author decided to simply hand a ball of Paper MagiClay to Ajana and invite her to play with it and do what ever she liked with it. Some discussion was initiated by the author who invited Ajana to describe the feeling, smell and texture of the MagiClay, to which Ajana readily responded. Whilst chatting in this manner and watching television, the author was surprised to see Ajana form a bowl-like shape out of the MagiClay. The author took the bowl away to dry but on second thoughts decided to return with it to explore further Ajana's interactions with the object she had created. When shown the item again Ajana, as on some previous occasions, asked who had made it. When asked if she could tell the author what the object was she stated that she did not know.

At this stage the author invited Ajana to have a "conversation" with the object, to talk with it and tell it what it felt and looked like. Although initially hesitant in response to the unusualness of this request she did enter into the activity and subsequently gave the object the name of "Bowl". When asked if she would like some more MagiClay to play with she enthusiastically responded that she would. Ajana went on to make a total of five MagiClay figures, which are shown below in Figures 6 through to 9.

Each time a new item was created, Ajana was invited to place it on a window shelf to dry with the previous figures she had created. Each time she was unable to remember or recognise the items she had already made and needed continuous prompting to differentiate her group of objects from other objects on the shelf. Despite this, the author recognised a level of playfulness and humour in many of her responses to the author. To explore this further the author engaged Ajana in a game which explored different purposing of a couple of the items, resulting in an imaginative game of "tea parties".

This was the most reactive and responsive Ajana had been, not only in the art therapy sessions but on the ward in general.

Ajana was discharged on Thursday March 28, 2013, before any further sessions could be undertaken.

Figure 6 - First item, "Bowl"


Figure 7 - Second item, "Vase"


Figure 8 - Third and fourth items, "Rabbit" and "Milk Bowl"


Figure 9 - Fifth item, "Milk Pourer"


Final Observations Regarding Sessions

After a series of exploratory sessions, Ajana was seen to engage most confidently, responsively and interactively when play was involved. It was within this context that she displayed a sense of humour and joyfulness out of character to her general levels of nonengagement displayed day to day on the ward. Throughout the course of the art therapy sessions Ajana was observed to move from being compliant and lacking self initiation, to creating without direct instruction, specifically during the final session. She also progressed from responding only to direct questions and being non-committal in her responses, towards occasional self-initiated comment and playful "banter".

A final conclusive diagnosis was not arrived at as a result of her admission. A working diagnosis of psychogenic amnesia of unknown cause is the current determination. Taking into account Ajana's history, which entails a prodromal sequence of decisions that had significant negative results and potentially produced excessive levels of internal conflict, and in the light of her responsiveness to play, it is hypothesised by the author that Ajana would benefit greatly from encounters with play therapy.

Play is a place where there is no potential for mistakes to "bite back".

Play is where the consequences of wrong decisions are not encumbered with guilt, fear, judgment or condemnation, whether from others or oneself.


Reflexivity - Learning About Self in The Therapeutic Relationship

In reviewing his own professional development encountered in the therapeutic relationship undertaken as described in this case study, the author recognises a range of important lessons. Many of these relate to the author's desire to "please" the other professionals in the team, which at times clouded his engagement with the client.

As a result of this need for a clearer understanding of his role within the team, the author approached members of the team via email, asking a series of questions, some of which were related to this issue. Whilst there are still some responses to come in, the author has been pleased to note that all received so far have commented on a place for art therapy in working therapeutically with the client and providing a broader representation of the client to the team that extends their view beyond the clinical nature inherent in the unit's operating framework. This is comforting as the author believes this is more attuned to his own understandings, theoretical stance and desired future directions as a practising professional, and plays an important complimentary role within the Neuropsychiatry Unit's diagnostic model.

Throughout the entire process the author was constantly battling with a desire to conform to perceived expectations such as those mentioned in the previous paragraphs, as well as those imposed by the author himself in terms of "sticking to the plan". The sessions worked best, however, when the author was willing to be responsive to and guided by the needs and counter-responses of the client. This also extended to the difficult realisation that art therapy does not always necessarily involve "doing art", there being a place for encounters which extend the therapeutic trust relationship.

Seeking to make a "connection"; developing a trust based relationship; honouring the here and now needs of the client; providing safety and a sense of being held in a state of "going on being" (Winnicott as cited in Ogden, 2004, p. 1350) - all these are essential to the client's process of "unfolding" and finding insight and growth.



Cooper, M. (2003). Existential therapies. London,: SAGE Publications. Reprinted 2011

Dewhurst, R. (2013, May 2). RE: Art Therapy and Nψ [E-mail to the author]. Personal correspondence from Neuropsychiatry Unit Occupational Therapist.

Diagnostic and statistical manual of mental disorders: DSM-IV-TR. (4th ed.). (2000). Washington, DC: American Psychiatric Association.

Moon, B. L. (2009). Existential Art Therapy: The Canvas Mirror (Third edition ed.). Springfield, Illinois: Charles C. Thomas.

Ogden, T. H. (2004). On holding and containing, being and dreaming. The International Journal of Psychoanalysis, 85(6), 1349-1364. doi: 10.1516/0020757042684078

Roberts, R., & Thomas, M. (2005). Zentangle [Zentangle kit including information booklet, demonstration DVD and resource materials]. MA, Whitinsville. For more information visit the Zentangle web site at

Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology, 21(2), 95-103. doi: 10.1037/h0045357

Seligman, R., & Kirmayer, L. J. (2008). Dissociative Experience and Cultural Neuroscience: Narrative, Metaphor and Mechanism. Culture, Medicine and Psychiatry, 32(1), 31-64. doi: 10.1007/s11013-007-9077-8

Sexton, A. (1981). Ringing the Bells. In The complete poems (pp. 28-29). Boston: Houghton Mifflin.

Staniloiu, A., Markowitsch, H. J., & Brand, M. (2010). Psychogenic amnesia – A malady of the constricted self. Consciousness and Cognition, 19(3), 778-801. doi: 10.1016/ j.concog.2010.06.024


Appendix A


And this is the way they ring

the bells in Bedlam

and this is the bell-lady

who comes each Tuesday morning

to give us a music lesson

and because the attendants make you go

and because we mind by instinct,

like bees caught in the wrong hive,

we are the circle of crazy ladies

who sit in the lounge of the mental house

and smile at the smiling woman

who passes us each a bell,

who points at my hand

that holds my bell, E flat,

and this is the gray dress next to me

who grumbles as if it were special

to be old, to be old,

and this is the small hunched squirrel girl

on the other side of me

who picks at the hairs over her lip,

who picks at the hairs over her lip all day,

and this is how the bells really sound,

as untroubled and clean

as a workable kitchen,

and this is always my bell responding

to my hand that responds to the lady

who points at me, E flat;

and although we are not better for it,

they tell you to go. And you do.

(Sexton, 1981, pp. 28-29)