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Art Psychotherapy, Borderline Personality Disorder & Dialectical Behaviour Therapy

Written by Megan Shiell, Published in ANZJAT October 2008 Volume 3. Number 1

ABSTRACT

This paper examines the symptoms of Borderline Personality Disorder (BPD) and the current models of treatment. As a commentary and case study it sets out to review how Art Psychotherapy can be used in conjunction with Dialectical Behaviour Therapy (DBT) with clients having BPD . It sets out to address how Art Psychotherapy can play a unique role in the treatment of clients with and what is missing in other forms of treatment. It addresses how Art Psychotherapy can be an adjunct to other forms of psychotherapy.

The Art Psychotherapy literature over the last 25 years is reviewed with particular emphasis on key theories and practices. The uniqueness of Art Psychotherapy is discussed with regard to 3 levels of experience for the client - the physical, emotional, and intellectual. By continuously offering a space, materials, and a therapeutic alliance, the creative process can facilitate the clients’ access to unconscious material and feeling states, which are not provided with the level of focus in other forms of therapy as in Art Psychotherapy. Art Psychotherapy also offers the opportunity to create an object, something original that can be reflected on by the development of an ‘observer self’ in a safe contained environment. Here the understanding of self-destructive behaviours of clients suffering with BPD can be enhanced.

The bigger picture is discussed: Could the client with BPD be mirroring a societal disorder? And, what can Art Psychotherapy contribute to addressing the sense of disillusionment and hopelessness that this client group experiences? The paper proposes that Art Psychotherapy, can offer Clients with BPD an opportunity to reconnect to themselves, to their families, to the community and repair the deficit that is often felt in their lives, namely, the chronic feelings of emptiness.

INTRODUCTION

The focus of this paper is to discuss how the theory and practice of Art Psychotherapy can offer a space for clients with Borderline Personality Disorder (BPD), to develop strategies to address some of the symptoms of this illness. In the latter half of 2005 I designed Art Psychotherapy sessions to support a skills based program called Dialectical Behaviour Therapy (DBT) in an outpatient private hospital setting in Sydney. The program offered an excellent opportunity to observe a range of experiences including. I was able to obsrve and reflect on the hospital system itself; how this particular skills therapy is conducted; other therapists’ techniques; the clients’ insights, and my own reactions to working in this environment. A case study of one of these sessions with ‘Tony’ is presented to illustrate how I adapted Art Psychotherapy as part of the DBT module entitled, ‘Interpersonal Effectiveness’.

DIALECTICAL BEHAVIOUR THERAPY AND THE USE OF ART PSYCHOTHERAPY

I have been fortunate to facilitate an Art Psychotherapy group as an adjunct to the Dialectical Behaviour Therapy (DBT) program offered at a private hospital in Sydney with an outpatient group of clients suffering from BPD. I will now detail the structure of the program and my involvement in designing appropriate Art Psychotherapy interventions with particular reference to what Art Psychotherapy can offer these clients that cannot be offered by other interventions.

There are three stages in the DBT program, the first is called ‘stabilization’. Here the primary objective is for clients to learn skills to decrease life threatening and quality of life interfering behaviours, such as depression, self harm, substance abuse, impulsiveness and suicide ideation. As a consequence of understanding and adapting these skills, clients can learn to move from dysfunction to control, therefore increasing life expectancy.

This first stage involves a commitment from the client to attend a one-day a week outpatient program of skills training, individual therapist consultation and telephone coaching for support between sessions. Skills training comprises learning four modules each taking nine weeks to complete, as follows:

  • Core Mindfulness
  • Interpersonal Effectiveness
  • Emotion Regulation
  • Distress Tolerance

The module named “core mindfulness” is regularly re-visited during each module to remind clients of their ability to monitor their reactions and behaviours.

Learning these skills enables clients to redefine the true or real situation as crises occur, therefore identifying their rapid and sometimes self-destructive reactions to their feelings. Diary cards to record emotions, vulnerability and behaviour are used to gauge a clients progress from week to week. A concept described as “chain analysis” is also used to identify vulnerability and links to situations that may arise which cause distress in between sessions. This gives therapists and clients alike, a concrete frame to discuss any difficulties at the beginning of each skills group.

Within this first stage of DBT treatment, I have used Art Psychotherapy to reinforce the skills topic of the first session. I will describe the session with Tony to illustrate how Art Psychotherapy can assist a client. Tony worked very quietly building a box, absorbed in neatly arranging stick, glue and stick. He was working with his ability to find a ‘cheerleader’ within, to make some statement that would nullify the negative myths that clients can develop about themselves.

FIGURE 1 - INSIDE TONY'S BOX

FIGURE 2 - OUTSIDE TONY'S BOX

Tony used the time in creating an object, not only to build a solid structure to support him, (a cheerleading structure). He used the process of art making to describe his needs more specifically. As he commented on his image he said how he really needed to keep his possessions, pencils, pins, and objects together. He needed a sense of order to be able to complete the assignments ahead of him. As we talked through the process of making the image, he also identified he needed a sense of solid containment to be able to hold all the pieces of himself inside a safe place. I reflected to him that his structure looked very strong, sturdy. He pointed out that he was recognizing that he did have more strength than he gave himself credit for.

The second stage of DBT is to find ‘ordinary happiness’. Here the l therapist addresses the client’s inhibited emotional experience and while, behaviour may be under control the client could be ‘suffering in silence’.

The third stage is to resolve a sense of incompleteness and achieve joy and inner sense of spirituality.

My impression of DBT, especially in stage 1, is that it plays a vital part in offering clients a sense of knowledge and containment in managing the turmoil that occurs by the symptoms of their illness. The images created and the process of making art enables the art psychotherapist to look at the emotional makeup of a person in a non-verbal and non-invasive way, something a skills program does not attempt to do. This one-on-one psychotherapeutic intervention, could run concurrently with any or all of the three stages of DBT. I envisage Art Psychotherapy being of great support to a DBT program both as a part of the group work as I have been doing, and also as an individual psychotherapeutic intervention.

SURVEY OF THE RELEVANCE OF ART PSYCHOTHERAPY TO DIALECTICAL BEHAVIOUR THERAPY

A survey of the clients in my Art Psychotherapy group over six afternoon document their opinions as to whether Art Psychotherapy helped to support their learning of DBT skills. The clients were asked to complete an observation sheet at the conclusion of every afternoon session and rate the Art Psychotherapy experience from 0 being negative to 10 being positive, in relation to these three questions.

The group rating was 7.5

1. How did you feel physically about doing Art Psychotherapy (using materials being in a space for creativity)? (It was noted that some participants have a history of obsessive-compulsive disorder)

The group rating was 7.9

2. How did you feel emotionally about doing art psychotherapy?

The group rating was 8.3

3. Do you think Art Psychotherapy connected you to the DBT skills discussed in the morning session?
To the left is a graph showing clearly the clients positive reactions to the relevance of using Art Psychotherapy as a support to reinforce DBT skills training.

Since 1998 very little literature has been generated about Art Psychotherapy and borderline personality disorder. The only article I could find was from the United Kingdom by Siri & Karterud (2004) who have done a study in order to present guidelines for day treatment programs for patients with personality disorders using art psychotherapy. It is noted in that article that out of all treatments offered, Art Psychotherapy rates the highest preference for patients in this environment. My impression of running Art Psychotherapy groups in this setting is that it is difficult on one hand be able to offer clients support as emotions are experienced, whilst concentrating on the skills to be reinforced for the session. The structure and boundaries of the sessions needed to be firm in order for issues of containment to be addressed.

LITERATURE REVIEW OF ART PSYCHOTHERAPY & BORDERLINE PERSONALITY DISORDER

Literature over the last 25 years in relation to Art Psychotherapy interventions suggests there are many ways in which it can be beneficial. As clients with BPD can feel a deep sense of abandonment and worthlessness, a therapeutic relationship could foster a sense of holding, being listened to, secure in the knowledge that in this space, they will not be left but encouraged to develop a stronger sense of self.

In discussing the literature several themes seem to be emphasised such as object relations issues, the splitting of sufferers with BPD, and the two-ness phenomena all necessitating the need for structure and support in building new ego strength. Silverman (1991) describes the anxiety these patients suffer as a consequence of their illness as “a rupture in the primary state of “at-one-ment” (p.87). She also comments that the patient has usually experienced impairment in their object relations in early development, that can also be re-lived whenever they experience an actual or threatened loss of a significant other. The authors consider there is a definite link in the importance of object relations theory as fundamental to the symptomology of clients with BPD. Cavallo and Robbins (1980) and Obernbreit (1985) emphasise the effectiveness of Art Psychotherapy in its ability to offer clients a way of communication that can transcend words and enable cohesion, a rebuilding of the ego strength through the metaphor.

In understanding the concept of “splitting” many authors referred to the psychodynamic principles of Freud (1933) where he states “where id was, there ego shall be’ implying the integration of internal and external realities. (Bateman 2000 p.75). Bateman explains the concept further:
“Just as understanding between people can lead to reconciliation, so can self-understanding and insight lead to reconciliation with disowned aspects of oneself”.(p.75)

Bion (1962) comments that some clients cannot achieve the capacity to think verbally, they think through imagery, and Art Psychotherapy can offer a way of tapping into the primal image-sensations of infancy. In much of the literature reviewed Art Psychotherapy is considered as an effective way to retrieve primeval information relating to infantile experience. Silverman (1991) explains that the internal states of clients with BPD are extremely difficult to explain verbally as they are “sensation experiences that originate from a time of life prior to the development of language” (p.84). Silverman also comments that through the making of art, one can observe the way early affective states can be illustrated as well as defense patterns of fusion and splitting in early object representations (p.84).

Silverman discusses Grotstein’s (1979,1982,1983, 1984a,b) concept in relation to primitive mental states. The suggestion that a symbiosis occurs between two “twin” personalities. When he describes the organization of clients with BPD he suggests that the normal aspects of a client’s personality represses the “primitive (or psychotic) twin” (p.86). The image below of a half magazine picture and half drawing is a self-portrait of Silverman’s client ‘Karen’ which contrasts the normal self with the fear of a psychotic episode and displays this dual personality very clearly.

Figure 3 – Self-portrait of Karen

Silverman (1991) describes Art Psychotherapy as having a distinct advantage in identifying the psychotic twin in a tangible way for the client.

Kadish (1993) also suggests that interpreting the split, the separation of the good and bad feelings in BPD clients, in the safe contained environment of art psychotherapy, enables a client to experience whether feelings are real and true, and in so doing, the art psychotherapist can help mend a fragile ego. Cavallo and Robbins (1980) acknowledge these good and bad feelings and suggest that in the art psychotherapeutic relationship a bridge can be offered between this two-ness phenomena. The containment offered by being able to be a constant, a witness in a relationship with a client, is crucial as Silverman (1991), Teirsten (1991) and Willoughby et al (1998) agree, and the simile they use in describing the chaos they exhibit, the leaking out, is that they do not appear to have skin holding them in.

Silverman discusses a client using scissors had created an image by cutting many holes in paper. She comments “The holes and dots were her attempt to communicate the experience of not being able to “keep anything inside” the client saying, “I feel void and empty all the time”(p.88). Silverman also discusses that clients with DBT regularly express feelings of transparency and shame, “being unable to ward off stares from the outside world represented by arrows” (p.89)

Figure 4: Silverman’s client’s image entitled “shame”

This image reminded me of a one of Marie’s work, created as an Art Psychotherapy homework assignment I initiated for the DBT outpatient group. The task was to describe in an image how it feels when you are having difficulty managing your anxieties.

Figure 5 – Marie’s 1st image

Figure 6 – Marie’s 2nd image

Figure 7 – Marie’s 3rd image

Figure 8 – Marie’s 4th image

The client explained that in Image 1 (figure 5) she feels balanced and in control, note the eye is in the center of the box and she is looking out. Image two (figure 6) she is experiencing a build up of anxiety, fractured inside, eye is still central, however she experiences the feelings that she can look out but then looks back in with judgment. Image 3 (figure 7) she feels the lull before the storm, or crisis. She goes into an empty space, her eye is now on bottom of box and all eyes are on her. Image 4 (Figure 9) she feels that no-one can help her, her eye is on bottom of box, she feels totally fractured and everyone is inside her head pushing out, making the box crack. I found it interesting that the body part used in Marie’s box was her eye, her visual connection with inner and outer worlds. Containment was crucial for her after this session and her ability to analyse and test her reality of imagined or real fears through the metaphor of her art, was of great assistance to her.

Obernbreit (1985) offers direction in tasks and boundaries, which mirror structure for these clients, and has written clearly on approaches and case studies where the language of art can assist in differentiating fact from fantasy, a common behavioural dilemma for clients with BPD. Winniocott’s concept of the transitional phenomena was mentioned by all authors as fundamental to assisting this client group. Art Psychotherapy can offer a creative place to play, allowing a space to observe and re-master the sense of self that has not developed cohesively. As Teirstein (1991) comments the observing ego, the third person, can be established enabling the client to experience a separateness from their anxieties and adapted behaviours.

The literature appears consistent and informative. A concentration is made of the ability of the therapist to maintain a positive relationship with the client whilst reparation of the ego strength is being progressed. There was a repetition of the use of the circle as an image in case studies mentioned by Silverman and Terstein. I have used the circle image in the groups I have conducted, and have found this and other ‘frame’ images can assist in helping this client group to identify inner and outer concepts as well as something that creates a boundary, a container for the creative experience.

ART PSYCHOTHERAPY CAN OFFER A UNIQUE THERAPEUTIC INTERVENTION

In discussing the uniqueness of what Art Psychotherapy can offer this client group, I have identified three areas:

  • The Physical
  • The Emotional
  • The Intellectual

The physical (figure 9) “The Studio”

The Art psychotherapist supplies their expertise, the materials and the space for therapeutic intervention. The place itself can be the studio, or a designated room in a community or hospital environment, in a client’s home or outside perhaps under a tree. For the purposes of this description, I will describe how a room provided the therapeutic environment for clients I have recently seen. The room itself allows for a ‘potential space’ to be offered to a client, to feel a sense of belonging, a place to return to, a place where something of oneself is left behind but held. A safe place. Winnicott (1971) offers us particular insight into this client group when he suggests that play does not happen inside or outside personal boundaries but in the potential space between the two. The Art Psychotherapy itself and the room can offer a unique setting. It is a space where battles may be fought in a contained therapeutic space. Boundaries of time and use of materials can offer structure to a client with BPD where the art psychotherapist can make observations of behaviour and anxiety levels in a non-judgmental environment.

Case and Dalley (1992, cite Schaverien, 1989) describes what can take place in the Art Psychotherapy room as follows: “Whatever happens here is split off from everyday existence and is observed, rather than acted upon. This is crucial because, without this space set apart, there is the inclination to behave and respond spontaneously, as we do in our social relationships. Here the frame provides a setting where the therapist can maintain a certain objectivity, a therapeutic distance. This allows the client to make a split which enables her both to regress and also to function as an observer of her own behaviours”. (p.20)

The materials offer a continuity of experience. They are always there, in the same position. A visual reminder of consistency is present; they can be used for exploration and play, to put down, to change one’s mind, to return to their place. Something one can touch, use and clean to create something new with. Silverman explains Ogden’s (1989) concept that a unique form of anxiety arises if sensory impressions are impaired during the earliest stages of life. She states “These impressions become the principal media for the creation of psychological meaning and the rudiments of the experience of self” (p.87). In a form of therapy where one is exposed to using materials, touching, cutting, exploring with media, an observation of early impairment is possible. The materials themselves can offer a tool to express emotions otherwise extremely difficult to access or verbally describe. There is the opportunity to make, re-make, destroy, view, ignore and be free to make choices.

The most unique aspect of Art Psychotherapy is the image or tangible object, a product, a creation that is fixed, visual, real, and able to be looked at again and again. It is a reminder of the room, the materials, of the therapeutic session and of the relationships developed here. This image or object belongs to the creator and can be used freely by the client to communicate feelings and emotions. The sense of identification, understanding and attachment felt when making something that attracts no judgment is important to a client’s building of self-esteem.

The emotional (figure 10) – “The group”

The emotional expressions of the client can be explored through art psychotherapy. Reactions can be observed by the therapist and the client before, during and after the process of making the artwork particularly in relation to sharing and engaging in an activity that allows feelings to be experienced. Robbins (2001) suggests that therapy should not be in making the unconscious conscious for this client group and suggests “That this is not possible, as the disparate systems of mental structure lack integration and cohesiveness. The task, therefore, becomes one of building rather than uncovering, and of completing lost dialogues of the early maternal matrix”(p 59). He comments that the knowledge of what the unconscious interpretation may be is of little significance. He refers to the premise that if reparation of object loss is the goal of therapy, then it is in the expression of empathy in the therapeutic relationship that can mirror emotional responses to the client. This would give the client the courage to “live through her feelings of pain and abandonment”(p.59).

One of the symptoms of BPD is a feeling of extreme emptiness, as though a page is missing in their development book. Fundamental to their understanding and bearing of these feelings is acknowledging that someone is prepared to sit through the emptiness with them. The art psychotherapist can be witness to a client’s reactions and patterned behaviours through observation of the non-verbal expressions of the client.

The experience of containment, being supported, with the therapist as a witness is a place where clients can feel safety and respect. Boundaries are observed and reinforced enabling a client to notice how to protect themselves from being overwhelmed by outside influences. To explore emotions in such an environment can build self-esteem and confidence in knowing that they can communicate difficult feelings in the care of someone they can trust.

Bion (1959) in Case and Dalley (1992) describes “the analyst as a container for the patient’s intolerable experiences” (chap.3, p.63). During therapy, there will be many occasions where containment is a variable in the relationship and where the therapist must ensure that enough sense of inner security is present in order to offer analytical holding to the client.

It will be in the moving between being “contained” and being “uncontained” in the therapeutic relationship that the client’s confidence will grow. The strategies learnt will empower clients to develop their own form of personal holding. If a therapist can show the client they can sit with them and endure the same distress they are experiencing, the therapist can give the client confidence that emotional difficulties can be tolerated and worked through.

The intellectual (figure 11)- “The observer self”

The intellectual relationship with the art psychotherapist in the safe setting of the session, enables a client to be helped to identify the ‘observer self’. The therapist can mirror this by witnessing the interactions of the client and the artwork. This could help a client suffering from BPD to attempt to confront their lack of inner and outer feelings.

The ability to reflect on what images could contain and how the process of creation felt, can assist the client to allow time to think, make their own interpretations and consider decision making rather than to act impulsively. It is often a new experience for a client to develop the ability to observe from a distance, as their anxieties may be at such a high level that they cannot challenge thoughts that are painful for them, they would rather react and avoid the feelings. Silverman quotes Bion (1983) that the patient through Art Psychotherapy can “think the thought” something previously extremely difficult for them. Silverman states “the concrete, graphic representation of images and emotions makes it easier to label internal states, rather than drifting in a world of sensation-dominated impulses” (p.107).

I will refer back to DBT for a moment in explaining the similarities in the concept of the term ‘wise mind’ and the expression ‘observer self’ in art psychotherapy. This diagram is part of the explanation in the mindfulness module of DBT.

Figure 12 - Symbol from Mindfulness module DBT skills

In Art Psychotherapy developing an ‘observer ego’ offers this contemplative ability and also the possibility for ‘psychological space’. Robbins (2001) writes that the art itself can be an organizer or a container that can mirror internal object relations as well as developmental problems and any associated defenses. He discusses how the therapeutic relationship and the art together offer a safe place to pursue confusion around the internal world of a client. He comments that it is the place Winnicott calls ‘transitional space’ (1971), a space neither inside nor outside. In an afternoon Art Psychotherapy session following the subject of recognizing one’s ‘wise mind’, I asked the group to create an image that could represent this. It was in the description by a group member previously referred to, Susan, that the value of creating an ‘observer self’ was accentuated through the making of this image.

Figure 13- Susan’s image of wise mind

Susan verbally describes her feelings through the use of the metaphorical meaning of her collage, that in her emotion mind she feels that her head is splitting, broken, and that time is slipping by. She put images of colanders in this side of the picture to represent her feeling that it is such a strain for her; everything she feels seems to be strained through and has a sense of leaking through the holes. (this leaking out sensation has been previously referred to in this paper p.14).

She talked about her reason mind as a sense of always having everything in order, part of her obsessive compulsive disorder which is a major issue for her in everyday life. Nothing can touch the ground, everything must be held up, tied on, held tight. She explained that even birds and dragonflies get stuck on the clothesline; they can’t fly away, that is the way the facts are in her reason mind. I reflected how powerful image making can be as in Susan’s case with her OCD behaviours, the items attached to the clothes line were of an unusual nature.

Her image for wise mind is a beautiful woman in a glowing gown, elegant and sophisticated, lifting her evening gown to show her strong sports shoes. Susan said the contradiction the image with these differing parts of beauty and strength appealed to her identification that she needs to have her feet firmly planted on the ground. She said she also needs to have both parts, beauty and strength working for her simultaneously.

I have noticed in the images produced that unconscious material always comes into play, even in directed sessions and it is in the containment of these images where a new awareness can be created. Schaverien (1992) explains: “It is the means through which the subjective and objective nature of the patient’s experience is mediated.” She describes the picture as instrumental in psychotherapy, as a means of “establishment of a conscious attitude to the contents of the unconscious mind.” (p.11,12). Schavarien talks of the picture made in a therapeutic setting as having the power to “‘uncloak’ an image of which the artist was previously unconscious”(p.7).

My impression of the session for Susan was that she had experienced the safety in Art Psychotherapy to express herself and one could observe her sense of confidence and excitement in the new way she was recognizing her feelings without fear, through the image. She said she understood the concept of ‘the observer-self’.

Clients suffering with BPD can feel a deep sense of abandonment and worthlessness, a therapeutic relationship fostering this kind of interaction could facilitate a sense of holding, being listened to, secure in the knowledge that in this space they will not be left but encouraged to develop a stronger sense of self. Sharing of associations/perceptions of the images could stimulate discussion and assist in supporting more helpful belief systems. Cavallo and Robbins (1980) noted that creating images to stimulate clients interaction or alongside clients was useful. I consider this could be an approach that would be helpful if it allowed clients to feel more at ease with the process of creativity.

TRANSFERENCE AND COUNTERTRANSFERENCE

It is essential for the therapist to observe and understand the transference and countertransference occurring in the relationshipAn art psychotherapist’s own self-care in using professional supervision and internal supervision, especially in relation to countertransference, is an essential part of being able to offer analytical holding to a client. The aim of the therapist’s own supervision is not to intellectualize the experiences with clients but to enable an understanding of their own feelings and not discharge them like the client does.

Case and Dalley comment that “transference and countertransference” develop through the response to the image itself” (p.63). They cite Heimann (1960) who proposes, “The therapist’s feelings or countertransference can be understood as a useful indicator of the patient’s state of mind” (p.63). If a therapist can feel the distress, recognizing it belongs to another, she could be in a position to hold on to it ‘like a mother’ and send it back to the client in a modified form. In this interaction between intrapsychic worlds, new meanings can be experienced. In the therapeutic relationship if this interaction is repeated over time it can enable the rebuilding of the internal object, as Case and Dalley cite Segal (1975:135) puts it “it is a beginning of mental stability”(p.63) Reed (2005) reminds us of the value of countertransference as follows:
“If the goal of psychotherapy with disorders of the self is to empower the real self and to decrease the false defensive self by working through the abandonment depression and modifying the maladaptive defenses, then one of the most useful therapeutic tools is countertransference” (p.32).

Another emphasis in this article is the challenge of the psychotherapist to hold on to a sense of a real self whilst being tested in most interactions. The time for self-reflection is crucial to keep open to meanings and understandings of our client’s images and communications.

I created this work after several DBT group sessions with clients. It allowed me to experience through my own feelings of being consumed by the work, how it may also be for the clients. I am buried underground with the flow of a river of extreme anxieties trying to reach the light and structure of supervision.

Figure 14 – Self reflection

DISCUSSION

I am drawn to the way clients with borderline personality disorder bring their sense of abandonment trauma into the present. Its as though there is an urgency to be alive, that the past and the future cannot offer them a sense of belonging, having a relationship. Moon (1990) comments “This is because of the borderlines inability to conceive relationships as a whole but, rather, as an unconnected string of parts”.(p.119) I have noticed that the clients in the Art Psychotherapy group I have been facilitating, seem to have an aura of disjointedness, at some times I see a omnipotence and in the next moment I see disillusionment, always within the frame of isolation and loneliness. The opposite feelings of wanting to belong and at the same time feeling that what is the point, a hopelessness, are often expressed. In being able to use the metaphor of images in making art, clients can express these feelings and gain an opportunity for them to be acknowledged and seen, without judgment. As Moon notes:
“The wisdom of thousands of years of humankind’s struggle to understand itself, to be with others and find meaning in life has too often been replaced with the search for measurable goals and scientifically verifiable data. We have reduced beyond recognition the concerns that make us most human and we miss our life’s metaphors.” Moon (1990 p.120).

Kramer and Weiner (1983) quote Psychiatrist Richard Restak author of “The self seekers”. Restak asks us is the increase in borderline pathology related to the decrease in structure within contemporary society? (p.78) They also ask the question is the volatile relationship with this client group, therapists, emergency wards and hospital staff, giving us a cue to a concept of a system representing the tension experienced in society. They suggest that perhaps clients are being diagnosed more with BPD for the reason that mental health professionals need to “fill the theoretical vacuum with elaborate theories to soothe their own frustrations” (p.72) acknowledging that this group of clients are inherently difficult to treat.

There are questions to be asked as to why this client group have grown and perhaps we need to look further at the reasons for what Moon (1990) calls “the changing face of illness”. Could it be more than a group of people who present as though they have one foot in the womb and one foot in the world? Is it always a result of early impairment in object relations? Could it be a repeated intensifying reaction to the changes in our world and the pressures we feel as a society? Could something have been lost in our family structures, our societal structures that leaves us with an empty feeling, boredom, a lack of connection? Is it a co-incidence that clients with BPD are often diagnosed at adolescence when they are attempting to develop a stronger sense of identity away from family?

Moon (1990) suggests there has been a movement from “id-oriented psychologies to ego psychology” (p.117). He looks at “the etiological factors and how they apply to what he considers to be the dominant pathology of our era, borderline personality”. He suggests that there could be many components to this emotional dysfunction some of which could be “genetics, biology, family milieu, natural and cultural factors along with fate and intra and interpersonal colorations”. (p.117)

CONCLUSION

In this paper I have described how Art Psychotherapy can assist in the treatment of clients with borderline personality disorder. I have detailed the symptoms of this disorder, the current treatments available, relevant Art Psychotherapy literature and drawn on my experiences in designing Art Psychotherapy sessions within a dialectical behaviour therapy framework.Art Psychotherapy offers a unique opportunity to process and to access the unconscious material. Willoughby, Booth and Pearce (1998) state:
“Because in the process of art-making some dissolving of conscious control is involved, we as art therapists are familiar with the dipping in and out of the potential chaos of undifferentiated experience and of trusting the objective nature of the art work itself to hold this safe, and in therapy to make available for recognition and acceptance. In this lies the core of the potential value of art therapy for this client group” (p.71).

A concept that would be useful for this client group is a Directed approachs in the Art Psychotherapy session would be useful in encouraging problem solvingdecision making with materials and ways of making art. With the constancy and support of the art psychotherapist the clients could practice coping with the symptomatic feelings of frustration, anger, negativity, emptiness and impulsivity. An unstructured approach using Art Psychotherapy with this client group would be unsuitable. It is a constant challenge for them to make decisions and problem solve and until their ego strength is re-established, a broad and unstructured experience as might alarm them and cause confusion and panic. Structure and consistency is critical for this client group. and I This adaptation of Art Psychotherapy to the skills based program in the DBT context has provided containment and support which is of primary importance. The learning of positive ways to communicate, regulate emotions, tolerate distress and control impulsive reactions whilst being mindful is illustrated in this paper.

I am confident that Art Psychotherapy as an therapeutic intervention in conjunction with DBT enhances the clients understanding of the skills concept through the use of the metaphor. I envisage an art psychotherapist being involved, in designing sessions to enhance the learning of DBT skills within the group environment. A cohesive approach would be for the art psychotherapist to a co-facilitator in the verbal part of the skills course and in the activity section of the group to use Art Psychotherapy thereby supporting and reiterating the skills taught on the day through art making.

I also recommend that Art Psychotherapy be used as an individual intervention on a weekly basis. Sessions would be held with the art psychotherapist, being the primary therapist, who would work closely with the DBT team leader and co-coordinator of the outpatient program. This structured focus could assist in rebuilding the knowledge and skills needed to improve the client’s quality of life always within a contained framework.

This paper has looked at the bigger picture of the borderline phenomena. If in fact our way of life has changed and affected the feelings of security and safety in vulnerable members of our society, how do we re-build our sense of self? Art Psychotherapy could play a role in, offering a time and space for not only understanding our inner psyche as individuals, but also for reconnection to carers, affected families and the community. In Art Psychotherapy boundaries can be explored, emotions can be tested, interpersonal skills can be rehearsed, trust can be experienced, all with the empathetic response of a psychotherapeutically trained professional. This is the unique environment of the metaphor where reparation of the deficit felt, can be understood and achieved.

Figures 15 and 16 are a measure of the combined effect all of the above experiences. The clients agreed that this was a challenging yet bonding experience. Individual paintings were passed on to another client after three minutes. At the end of the time allowed, they stuck the pictures together representing a roller coaster ride; something they agreed was a metaphoric representation of their disorder. They then cut all pictures in quarters and stuck them back together randomly. The picture now hangs in the DBT room at the hospital.

Figure 15 – Group roller coaster

Figure 16 – Group joint picture

In conclusion, I propose that Art Psychotherapy can fill the gaps of verbal therapies for this client group and add yet another dimension of understanding to them. Art Psychotherapy can work in conjunction and within the DBT skills program . Art Pscyhotherapy offers a uniqueness by enabling clients to have a deeper understanding of their inner frame of behaviour and development through the use of symbols and metaphors in a safe, contained therapeutic environment. It is noted that DBT does not aim to address the underlying emotional issues for clients, the focus is to learn the skills to moderate behaviours in order to have a ‘life worth living’, free from the disruption of the symptoms of DBT.

The consistent physical environment of the room, materials and the original tangible object created offers a unique experience. The tangible object can offer the opportunity for the ‘observer ego’ to be developed, something that can mirror the idea of ‘time-out to think’ which is a characteristic that these clients find difficult to access, they often like to fill every space of time.

The ‘observer ego’ not only enables reflection of emotions, but also can assist in analysing decision making, therefore allowing more time to consider their reactions to events. This also mirrors the ‘wise mind’ concept of DBT however creating an image, allows the client to have a visual reminder to reflect on, in their own time and space. This unique opportunity to have a reminder of skills and emotions may provide valuable assistance during crises.

Art Psychotherapy can deepen understanding, within the therapeutic relationship inside the frame of creativity and offers an emotional space for exploration of difficult feelings and emotions. Art making can act as a mirror to show clients alternative approaches and ways of dealing with their overwhelming anxiety.


Illustrations

Figure 1 - Inside Tony’s Box
Figure 2 - Outside Tony’s Box
Figure 3 - Self-portrait of Karen
Figure 4 - “Shame” Silverman’s anonymous client’s image
Figure 5 - Marie’s 1st image
Figure 6 - Marie’s 2nd image
Figure 7 - Marie’s 3rd image
Figure 8 - Marie’s 4th image
Figure 9 - The Physical ( The Studio, M.Shiell)
Figure 10 - The Emotional ( The Group, UWS)
Figure 11 - The Intellectual ( Observer Self, M. Shiell)
Figure 12 - Symbol from Mindfulness module DBT Skills Manual
Figure 13 - Susan’s image representing ‘wise mind’
Figure 14 – Self reflection (M.Shiell)
Figure 15 - Group roller coaster
Figure 16 - Group joint picture
Figure 17 –A metaphor of what Art Psychotherapy offers( M. Shiell)

 

References

Bademan, A. Brown, D. & Pedder, J. (2000) Introduction to Psychotherapy: An outline of psychodynamic principles and practice. (3rd Ed.) Routledge: London

Cary-Boothe, C. & Robbins A. (1995) Working with opposites: Developing a “middle path” between patient and therapist. Pratt Institute Creative Arts Therapy Review. Vol 16.

Case, C. & Dalley, T. (1992) The handbook of Art therapy. Routledge: London

Cavallo, M. and Robbins, A. (1980) Understanding an Object Relations theory through a psychodynamically oriented expressive therapy approach. The Arts in Psychotherapy, Vol. 7 pp.113-123, Ankho International Inc. USA

Corey, G. (2001) Theory and Practice of Counseling and Psychotherapy (6th Ed.) Wadsworth/Thomson: Belmont CA

Deco, S. (1998) Return to the open studio group. In Skaife, S. and Huet, V. Art Psychotherapy Groups, Routledge: London

Greene, H & Ugarriza D. (1995) ‘The Stably Unstable’ Borderline Personality Disorder: History Theory, and Nursing Intervention. Journal of Psychosocial Nursing Vol 33.No.2

Hannig, P. (1998) Borderline Personality Disorder (BP): A Profile

Hartwich, P. & Brandeck, R. (1997) Computer-based art therapy with inpatients: Acute and chronic schizophrenics and borderline cases. Arts in Psychotherapy Vol 24 (4)

Jadi, F.& Trixler, M. (1981) Hypnagogic hallucinations in art therapy Arts in Psychotherapy Vol 8(1).

Kadish, A (1993) How to not make interpretations, when interpretations are being begged for: A study of interpretative techniques with borderline personalities. Pratt Institute Creative Arts Therapy Review, Vol 14, pp. 44-49

Kramer, R. and Weiner, I. (November 1983 ) Psychiatry on the Borderline, Psychology Today

Kohut, H. & Wolf, E.S. (1978) The Disorders of the Self and their treatment: an Outline. International Journal of Psycho-Analysis, 59. (pp. 413-425)

Lachman-Chapin, M. (2001) Self psychololgy and art therapy. In Rubin, J.A. Approaches to art therapy: Theory and technique (2nd ed.). Brunner-Routledge: New York

Linehan, M. (1993) Mindfulness Module: Skills training manual for Treating Borderline Personality Disorder: The Guildford Press, New York

Linehan, M. Cochran, B. and Kehrer, C. in Barlow, D. (2001) Dialectical Behaviour Therapy for Borderline Personality Disorder: Clinical Handbook of Psychological disorders (chap 11, pp. 470-519): The Guildford Press. New York.

Masterson, J.F. (1983). Treatment of a Borderline Adolescent. New York: Brunner/Mazel. Inc.

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Schaverien, J. (1989) in Case, C. and Dalley, T The Handbook of Art Therapy (chap. 2, p. 20)Routledge, London.

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Shiell, M. (2001-2005) Essay on Containment, Literature Review, submitted to University of Western Sydney as part of Masters of Art Therapy Course.

Silverman, D. (1991) Art Psychotherapy: An Approach to Borderline Adults. In Landgarten, H. B.; Lubbers, D. Adult art psychotherapy: Issues and applications, Philadelphia, PA, US: Brunner/Mazel inc. (pp. 83-110)

Siri, J. and Karterud, S. (Sept 2004) Guidelines for art group therapy as part of a day treatment program for patients with personality disorders. Group Analysis Volume 37 (3) pp. 419-432

Teirstein, E.G.(1991) Developing: Art, mastery, self. Pratt Institute Creative Arts Therapy Review, Vol 12, pp. 16-29. (Peer Reviewed Journal)

Wadeson, H. (1980). Art Psychotherapy. Wiley: New York

Willoughby-Booth, S. and Pearce, J. (1998) On the edge. In Rees, M. Drawing on the Difference, Routledge: London ( chap 4. pp. 59-72)

Winnicott, D. (1986) Transitional Objects and Transitional Phenomena. Playing and Reality. :Penguin

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Contact

Contact Megan Shiell at ETC – Tweed Heads

0417 084 846

Registered Art Psychotherapist:
#HP2005N-208

Dialectical Behavior Therapist:
ACA Member #7159

Further Info

For further information on Art Therapy or Art Psychotherapy: www.anzata.org.