Inner Frame

Inner Frame

• Urban Location
• In-Patient Mental Health Ward
• Acute Admissions
• Short term Crisis
• 14-bed unit
• Older Adults (65+)
• Under Section/ requiring treatment and support for mental (and physical) health.

RECAP- The Setting

The Setting

• Delusional
• Bipolar
• Other

Largely Psychosis/ Psychosis-related diagnoses...

• Schizophrenia
• Schizo-affective

• Personality
• Paraphrenia

"Therapy" Room

Art as Therapyvs. Art as an Activity?

Entrance to the "Therapy" Room

Sessions have NEVER been referred to as... Therapy

• "Lessons" by nurses
• "Self care" by an occupational therapist
• "Fun activities" by a care worker
• "Nice hobby at the ward" by a staff member

Sessions have been referred to as...

• Craft Wire
• Sharpeners
• Scales/ Rulers
• Scissors
• Cutters
• Lolly sticks

No access to sharps/ potential sharps:-

• Watercolours, Acrylics, Oils, Poster Paints (Non-toxic)
• Crayons, Soft Pastels, Oil Pastels, Chalks, Markers, Pens
• Drawing pencils, Charcoal, Colour pencils
• Craft material, Non-toxic glitters and glues

• Different kinds of papers
• Clay, Plasticine

Materials: -

Dynamics

Psychosis has been conceptualized as involving weak Ego boundaries (McWilliams, 2011). The individual retreats to an inner fantasy world because the internal and external realities experienced are too traumatic. Different internal-external realities = Fragmented Self (Lavarenne, Segal and Sigman, 2013) They experience difficulty attending regularly and often miss sessions. Avoidance as self-defence, especially of 1-to-1s Fear of being annihilated (Atwood, Orange, & Stolorow, 2002)

• Hold boundaries but not too rigidly (BAAT guidelines, 2020)
• Clients are escorted to and from sessions
• Sessions can range from 30 to 50 minutes
• Consistent reassurance is needed
• Consent, confidentiality, intro to art therapy discussed
• Approach remains largely non-directive but often help is needed in initiating sessions.
• Check-ins
• Sessions may get cancelled if there is a serious risk of harm to self/others.

Therefore Boundaries must be both firm and flexible...

• Containment for their subjective realities and anxieties
• Safety and security
• Reassurance, acceptance
• Help restructure the ego
• Expand window of tolerance
• Help them develop healthy defences
• Help them mentalize
• support art-making: Help express and externalise using materials
• Remain person-centered, atuune therapy to patient needs

Aim to provide...

• No one understands my work

• Patients often refuse sessions, making me and my work feel unnecessary

• Avoidance and uncertainty
• Only get to see patients 2-3 times before they are discharged
• Too much to do in too little time
• Difficulty developing relationships and building trust

What it feels like...

• Supervision
• Secure Outer Frame
• Take handovers before sessions
• Panic Alarm
• Refuse/ end session if feeling unsafe
• Reach out to team for help/concerns
• Support from other creative therapy trainee
• Personal therapy
• Response Art
• See limited clients (2 per week)
• Do my best :)

How do I cope?

• "Anna" - Pseudonym
• Approx. 70 y/o Female
• Mother to 3
• European (Norwegian-Irish-French-English)
• Artist
• Third generation Bipolar
• On Medication

• Exhibits Classic Bipolar Behaviours: -

- Mania, hypomania, hysteria - Depression - Previously suicidal - Unpredictable behaviours

Clinical Work - Vignette

• Reassurance, prayer, redemption, religion
• Conversations with "Mr. God"
• Nicotine puff/vape
• Art-making
• Reassurance that she is a good mother
• Christmas, Snow

What calms her down?

• *Death by accident of young daughter (24 y/o) around 9 years ago
• War and death
• Racism, violence/ sexual violence

Triggers

Therapy with 'Anna' - 50 minute-sessions - Would refuse to leave or request another session immediately - No difficulty expressing through material - Did not feel the need for direction - Needed emotional support, containment, reassurance - Someone to talk and cry to - Often requested to have tea with me - Very polite. Despite extreme behaviours, it never felt that the anger/ aggression was directed at the therapist.

figure 11: Author's renditions of Anna's artworks

"Millions and Billions and Zillions of Tears..." - Anna

I have a hole in my soul...Like A Cavity

XXX... XXX

Everyone bleeds the same colour...x

Mon Bleu Angel

Session 2 - Themes: War, God, Redemption, Death

The world is weeping with love, Anna

UKRAINE

The world is weeping with love, Anna

UKRAINE

Jesus

Mon Bleu Angel

Transference and Countertransference...

Atwood, G., Orange, D., & Stolorow, R. (2002). Shattered worlds/psychotic states: A post-Cartesian view of the experience of personal annihilation. Psychoanalytic Psycholog, 19, 281–306. Crossref. McWilliams, N. (2011). Psychoanalytic diagnosis: Understanding personality structure in the clinical process (2nd ed.). New York, NY: The Guilford Press. Lavarenne, A., Segal, E. and Sigman, M. (2013). Containing psychotic patients with fragile boundaries: a single-session group case study. American journal of psychotherapy, [online] 67(3), pp.293–307. doi:10.1176/appi.psychotherapy.2013.67.3.293.

References