CaseStudyStroke.pdf

CASE STUDY: The role of art therapy as a potential space for the processing of

psychological and physical experience following stroke

ASSSESMENT AND REHABILITATION CENTRE (ARC)

Sheffield South West PCT Intermediate Care Services

February 2007

BACKGROUND

The shock of acute stroke reverberates not only through the cognitive, emotional and social functioning

of the individual sufferer, shattering their world, but also through family and community, constituting a

significant burden for all concerned.

For the individual, a stroke may leave them suffering with emotional, psychological and adjustment

issues as a result of the impact of the trauma on their physical and cognitive functioning. Coping

strategies, memory, learning skills, the ability to think or organise thoughts, emotional reactions,

behaviour, social interactions, relationships, communication, language and understanding can all be

affected. Because of this, the habits and skills developed to cope with trauma or change – to plan and

live life - can no longer be relied upon in the same way, often leaving the person feeling confused,

alone, unable to communicate, anxious and depressed.

ABOUT ART THERAPY

The Art Therapy (aka Art Psychotherapy) Profession is State Registered by the Health Professions

Council.

Art Therapy is a form of psychotherapy in which art and image-making play a central role within the

therapeutic relationship. In the three-way process between person, image and therapist the art media

acts as the primary form of communication; the person and the image-making process (rather than the

product) being most important. ‘The overall aim of art therapy is to enable a client to change and grow

at a personal level through the use of art materials in a safe and facilitating environment’. (British

Association of Art Therapists)

ART THERAPY & STROKE REHABILITATION

Art therapy is particularly helpful for people who find it difficult to communicate verbally, have suffered

trauma or who are facing times of adjustment and change. An image or colours or textures can express

complex thoughts and feelings that cannot be made sense of or put into words. As an unconscious form

of communication the images made are seen and understood alongside and with the patient. For stroke

sufferers, who may have been catapulted back to a state of helplessness and dependence and a world

without words or meaning, this creative space is one which holds the potential for: self expression and

non-verbal communication; the containment of feelings; and for finding form, colour, texture and

meaning to the physical and psychological experience of stroke. Through absorption in the art-making

process within the frame of the therapeutic environment, the individual may then begin to regain a sense

of their capacity to combine thought and physical action.

The complexity of image-making takes into account physical, cognitive and psychological factors,

being well suited to the rehabilitation process. Art therapy offers a medium which bridges physical and

psychological experience , and enables:

•

the formation of a narrative for the individuals experience of incomprehensible thoughts and

feelings that may have no words, leading to greater understanding and awareness of what has

and is happening, more meaningful communication , and the amelioration of anxiety and

depression .

•

the working through of losses , leading to acceptance of damaged parts of self : body and

mind, adjustment to limitations and a more positive outlook on life .

•

the channelling of emotional and physical energies in a constructive and potentially

coherent way , leading to a more courageous and flexible exploration of possibilities , and

resulting in more adaptive responses to life’s challenges .

•

the mastering of anxieties , contributing to feelings of autonomy, control, dignity and

empowerment and the move towards independence and community .

SUPPORTING EVIDENCE

Healthcare Commission’s follow-up survey of stroke patients (2006, p.16)

“Having a stroke can have a detrimental impact on the psychological and emotional

well-being of a person. Depression and anxiety are common after stroke and

patients can feel abandoned when they lose the emotional and practical support they

receive in hospital. NSF for Older people states that support over a longer period for

patients who have had a stroke should include the provision of social and emotional

support to minimise any loss of independence and to help manage the

consequences of stroke”.

Key Findings. Reducing Brain Damage: Faster access to better stroke care. DOH/National Audit Office,

(Nov. 2005)

“Most people who survive a stroke will live for the rest of their lives with minor to

major disabilities as a result, and will be dependent to varying degrees on health and

social care”. (p.6)

“Stroke patients required services and therapies from many disciplines in health and

social care” (p.8)

Art therapy still has relatively unexplored potential for brain-injured and stroke patients, although there

are a growing number of art therapists working in neuro-rehabilitation (Weston 2005). In clinical settings

Art Therapists have expertise in working with, amongst others, those suffering from severe emotional,

behavioural and mental health problems; learning or physical disabilities; life-limiting conditions &

palliative care; brain-injury or neurological conditions; and physical illness.

The literature relating to art therapy and physical illness indicates that psychodynamic art psychotherapy

can provide a bridge for symbolic communication which offers an opportunity for patients to understand

themselves and feel understood by others (Fulton 2002, Skaife 1993, Waller 1991, Lillitos 1990, Wood

1990, Malitskie 1988, Cregreen 1992, Miller, 1984, Szepanski 1988, Wisdom 1997, Michaels 2004, Von

Sass Hyde 2002 ); providing a medium for the integration of distressing emotional experience which can

assist people in redefining ‘self’ (Lillitos 1990; Vasarhelyi 1989; Cregreen 1992; Kirby 1988; Simon

1981, 1982, 1985; Hill 1945, 1951; Wood 1990; Henzell 1988; Malitskie 1988; Szepanski 1988, Connell

1992; Byers 1995; Skaife 1993; Pratt & Wood 1998, Wisdom 1997, Michaels 2004).

PILOT PROJECT:

ART THERAPY & STROKE REHABILITATION IN INTERMEDIATE CARE SERVICES

In 2003 an art therapy service was piloted at ARC, an NHS multidisciplinary community-based

rehabilitation day centre in Sheffield. The service was implemented over a 2 year period as part of an

art psychotherapy training placement and offered one to one art therapy for varying durations from a few

weeks to 20 months. The service was integrated into the core team of medical and nursing

care/support, physiotherapy, occupational therapy, speech & language therapy and psychology.

Aim: Art therapy was sought out by the team in recognition of a lack of resources and a need for help in

dealing with patients suffering from emotional distress, adjustment issues, communication difficulties

and psychosocial problems that were impeding their rehabilitation. These issues were making it difficult

for the patients to make use of standard treatments, including verbal psychological interventions, and

without appropriate treatment there was concern about mental health and psychosocial deterioration.

Achievements: Attendance to sessions was very high and all the patients engaged fully with the

materials and process of art therapy, whereas some had been unable to make use of solely verbal

psychological approaches or were not considered appropriate.

The majority of patients who received art therapy gave qualitative feedback that indicated perceived

improvements in their general health state, the most important changes being that they felt…

• more worthwhile

• more sociable • more relaxed

• more in control

• more able to reflect on experiences

• more interested in things

Aspects of the art therapy process that they felt were very or most important were…

• expressing myself

• exploring my feelings

• choosing what I want to do

• having a space for myself

• having a session at a regular time

Summary

The project confirmed a need for community-based specialist expertise in dealing with stroke sufferers

who are struggling to adapt to life after stroke due to entrenched emotional and psychosocial difficulties,

and who are unable to make use of standard treatments and/or solely verbal forms of psychological

intervention in their rehabilitation.

The project also identified that, whilst some patients gained benefit from short-term art therapy

interventions, there was a need for extended periods of therapeutic time for some patients, in order to

allow for a working through of complex emotional issues impeding a move back to independence and

community, and that without this there was a risk of readmission to hospital or mental health

deterioration.

As a non-verbal treatment method Art Therapy …

was able to address issues around illness and loss of function in a less confrontational way

than a purely verbal therapy.

facilitated expression of issues related to loss of control, skill and function, changes in status,

and fears about further ill health and death.

enabled difficulties to be expressed and made manifest through the art materials and seen,

rather than denied, by the patient, facilitating the mourning process.

facilitated a capacity for control and autonomy, creating and generating change which can be

seen through the image-making process; allowing comparison between past and present and

offering a hopeful potential for change and life.

allowed space and time for patients to mourn their losses, come to term with the impact of

stroke on their physical and psychological functioning, to explore new approaches to life and

move on.

Debbie Michaels

Art Psychotherapist – Sheffield Care Trust

R E F E R E N C E S:

The British Association of Art Therapists (2005) Promotional leaflet

Byers, A (1995) ‘Beyond Marks’, in Inscape: The Journal of the British Association of Art Therapists , Vol.1:13-18

Connell, C (1992) ‘Art therapy as part of a palliative care programme’, in Palliative Medicine, Vol.6:18-25

Cregeen, Simon. (1992) ‘Seizure as symbol: an exploration of the symbolic meaning of an epileptic seizure within a

therapy relationship’, in Inscape: The Journal of the British Association of Art Therapists Spring, 1992: pp17-26.

Fulton, J. (2002) ‘Art Therapy and Chronic Illness: An Enquiry into aspects of service provision for patients with

atopic disease’, in Inscape: The Journal of the British Association of Art Therapists, Vol.7, No.1: 2-15

Kirby, D (1988) ‘Shame and the Use of health Care Services’, in Inscape: The Journal of the British Association of Art

Therapists. Spring:11-13

Lillitos, A. (1990) ‘Control, uncontrol, order and chaos: working with children with intestinal motility problems’, in

Working With Children in Art Therapy, Case, C. and Dalley, T. (eds). Routledge: London

Malitskie, Glynnis. (1988) ‘Art Therapy with Kidney Patients’, in Inscape: The Journal of the British Association of Art

Therapists . Spring, 1988: 14-17.

Michaels, D.A (2004) ‘Creating a Space for Thinking – can art therapy offer a potential space for the processing of

mind and body experiences following stroke? Dissertation – Post Graduate Diploma in Art Psychotherapy:

University of Sheffield

Pratt, M. & Wood, J.M. (eds) (1998) Art Therapy in Palliative Care: The creative response. Routledge: London

Skaife, S. (1993) ‘Sickness, Health and the Therapeutic Relationship: Thoughts arising from the literature on art

therapy and physical illness’, in Inscape The Journal of the British Association of Art Therapists . Summer:24-29

Simon, R. (1981) ‘Bereavement Art’,in American Journal of Art Therapy , Vol.20 (July):135-143

_______ (1982) ‘Peter: A Severely Disabled Patient’s Triumph Through Art’, in American Journal of Art Therapy ,

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_______ (1985) ‘Graphic Style and Therapeutic Change in Geriatric Patients’, in American Journal of Art Therapy ,

Vol.24 (August)

Szepanski, Mary-Rose. (1988) ‘Art therapy and Multiple Sclerosis’, in Inscape: The Journal of the British Association

of Art Therapists. Spring, 1988:4-10

Vasarhelyi, V. (1989) ‘What happened on Ben Nevis?’, in Inscape: The Journal of the British Association of Art

Therapists. Autumn, 1989:16-24

Von Sass Hyde (2002) ‘The Janus response: Art therapy within a neuro-rehabilitation setting’. MA Dissertation –

Diploma in Art Psychotherapy: University of Sheffield

Waller, D . (1991) Becoming a Profession: the History of Art Therapy in Britain (1940-1982) Tavistock / Routledge:

London.

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Therapy: new developments in theory and practice. Dalley, T. et al. (eds.) (1987) Tavistock: London

Weston, S (2004) ‘Arts Therapies and the Brain injury Pathway’. Draft paper for Sheffield Brain Injury Stakeholders

Group .

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Wood, M. (1990) ‘Art Therapy in one session - Working with people with AIDS’, in Inscape: The Journal of the British

Association of Art Therapists. Winter, 1990:31-35.

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