Art therapy in the rehabilitation of adolescent students with spinal cord injuries: A case study

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This case study highlights the usefulness of art as a therapeutic modality in the rehabilitation of adolescents with quadriplegia. It often is difficult to engage adolescents in verbal psychotherapy. Art therapy is shown to be an effective alternative means of self-expression that serves as a catalyst for adjustment. Draw-hags and clinical material from the therapy of a 13-year-old girl with quadriplegia resulting from spinal cord injury are presented. Themes of disturbed body image, isolation, and concern over control are evident in her work. The significance of these otherwise unexpressed inner conflicts is discussed in the context of her overall progress in rehabilitation.

Adolescents with quadriplegia present unique emotional problems during rehabilitation. They frequently exhibit denial (Geller & Greydanus, 1979; Gordon, 1987), which makes traditional forms of psychotherapy difficult. Furthermore, they may project anger over the disability onto the staff of the rehabilitation facility, preventing the formation of a therapeutic alliance. In addition to the general adjustment difficulties experienced by people with spinal cord injuries, adolescents often have developmentally congruent concerns regarding autonomy, control, and body image which may be difficult for them to articulate.

Art therapy is based on the concept that defense mechanisms commonly used in speech are not readily transferable to drawings (Labarca, 1979). Some clients are able to express their inner conflicts through art; thus the therapy provides a forum in which emotions can be revealed. Art therapy has been used successfully in health care settings to treat adolescents, including oncology patients (O'Neill, 1989; Walker, 1989) and anorectic patients (Wolf, Willmuth, Gazda, & Watkins, 1985). However, there has been no documented study of its use with adolescents who have spinal cord injuries.

In this case study, a brief introduction to the patient will be followed by a discussion of her artwork, a series of drawings rendered in individual psychotherapy sessions over a period of several months during an inpatient rehabilitation stay.
The Patient

J.C. entered an inpatient rehabilitation unit of a large general hospital at age 13, approximately 1 month after a boating accident that resulted in a C 5-6 complete quadriplegia. She was the youngest of three children from an intact middle-class family; her older siblings already had left home. Her parents described her as a superior student with many extracurricular interests, who often preferred the company of older children and adults to that of her peers. A large girl, J.C. could easily be taken for several years older than she really was. Prior to her accident, she had no history of major illness or hospitalization.

The day after her admission to the hospital, J.C. was visited by a medical psychology fellow, a member of the rehabilitation unit's multidisciplinary spinal cord injury treatment team, who saw her daily while she was in acute care. The fellow continued to see her three times a week after she was transferred to the rehabilitation unit.

During psychotherapy sessions, J.C.'s presentation and level of engagement varied considerably. At times she appeared friendly and cooperative, but she also could be withdrawn or resistant. Regardless, she consistently denied having any concerns or adjustment difficulties related to her spinal cord injury. She had little to say about being paralyzed except that it did not bother her to use a wheelchair. Overall, J.C maintained that her quadriplegia was "no big deal" and that she did not feel psychotherapy was necessary.

J.C.'s behavior on the rehabilitation unit presented a different picture. She was prone to periods of anxiety, primarily manifested through nausea and dizziness. She frequently asked others to do things for her that she was able to manage herself. Her progress in physical and occupational therapy was poor, mainly due to lack of motivation. When confronted about her slow progress, J.C. and her parents accused the unit staff of being demanding and incompetent.

J.C. was able to begin making pictures during psychotherapy through the use of a Wanchik writer, an adaptive device that allowed her to write and draw. These drawings revealed problems and conflicts she could not otherwise express.
The Drawings

A recurrent theme in J.C.'s initial drawings was one of somatic detachment, coupled with an overemphasis of the head and neck. Her initial self-portrait (Figure 1), which she executed at the therapist's request, depicted a large head on a stick-figure that seemed to illustrate her uneasiness with her own body. Her concerns also were expressed in drawings of animals, such as her impromptu sketch of a giraffe (Figure 2), in which she drew an elongated neck with minimal attention given to the torso and legs. This figure could be interpreted as representing her preoccupation with the site of her injury and her relative dissociation from the rest of her body. Similarly, a subsequent drawing of a teddy bear (Figure 3) ends at mid-torso, which on J.C.'s own body was the upper boundary of her paralysis. The omission of the bear's lower half reflects her dissociation from that part of her own body. Overall, these drawings appear to express J.C.'s sense of somatic disengagement from those areas of the body most affected by her accident, and a heightened attention to the head and neck.

In addition to themes of disturbed body image, many of J.C.'s initial drawings express isolation. Her self-portrait (Figure 1) contains only a superimposed image of her dog, suggesting, perhaps, that apart from this faithful friend, J.C. felt alone in the world. Similarly, her other animal figures were portrayed without background or context.

At the same time she created these images, J.C. was adjusting to the rehabilitation unit, struggling with expectations that patients learn to function as independently as possible and care for themselves. It was during this period that her anxiety heightened, primarily due to staff requests that she become more independent from her parents. Although J.C. did not talk directly about her anxieties, these drawings may be understood as representing her fears of abandonment and isolation.

As J.C. and her parents formed an alliance in opposition to the staff over her independence, J.C. began to include background scenery in her drawings. Several drawn during this time depicted figures in settings that contained a flower and the sun (Figures 4 and 5). J.C.'s attachment to her parents was very strong during this period, and we hypothesized that the flower represented her mother and the sun, her father. These pictures, however, also reflect a shift from the stark isolation of her earlier drawings. Although she relied mainly on her parents for protection, J.C. was now able to see her world as more secure. She was able to express solidarity with her parents, frequently commenting to her therapist that she was a member of a family that was not going to be split by the rehabilitation team.

During this time, changes in body image also were occurring. As previously noted, her initial self-portraits displayed stick-figure or poorly formed bodies (Figures 1 and 4), in contrast to her sketches of staff members, whom she drew with full bodies. In response to encouragement from her therapist, J.C. began portraying herself with a complete body (Figure 6). She also became more attentive to her appearance, taking care in her choice of clothes and with general grooming. J.C. was beginning to reclaim and acknowledge her body as a valuable part of her self.

As J.C.'s discharge date approached, she drew figures troubled by predators. Figure 7 is especially revealing; J.C. described it as a "good pumpkin being haunted by a bad witch." She said that the pumpkin could not escape from the witch even though the witch was just flying home. We noted that J.C.'s mother frequently called her "Pumpkin" and that in a previous session, J.C. had referred to her therapist as "the Wicked Witch of the West." This drawing seems to record her concern over termination from therapy as well as her fear of what the therapist was telling her. In addition, J.C. may have been expressing general anxieties over discharge and readjusting to her home without staff members to aid her. But J.C.'s controlled silence was as rigid as the smile on her pumpkin, and she acknowledged neither her concerns nor the meaning of her drawing.

A final drawing completed just before discharge depicted a rainbow with a pot of gold (Figure 8). This picture appeared to illustrate J.C.'s optimism about the future. Like a rainbow, J.C. had weathered a storm but now felt as though skies were beginning to clear. Although she was unable to speak of her confidence about the future, this picture conveyed her feelings on discharge, and to the therapist, it seemed like a parting gift.
Discussion

As this case study suggests, art therapy may be useful with adolescents who have sustained spinal cord injuries. Topics such as self-concept, body image, and relationship to others can be explored indirectly. In addition, adolescents may experience a renewed sense of mastery as they begin to produce images on paper.

J.C.'s artwork displays a progression of themes common to adolescents with quadriplegia: from denial to reclaiming one's body, autonomy, and hopefulness. Through her drawings, J.C. was able to process material that likely would have remained otherwise unexpressed. Because she could maintain distance from her feelings by projecting them onto her drawings, J.C. began to work through unspoken concerns.

Controlled studies would be necessary to document the relative efficacy of art therapy for adolescents with spinal cord injuries. Given the usual difficulties of engaging these patients in verbal psychotherapy, art therapy has the potential to be an effective means of self-expression and a catalyst for adjustment.

Requests for reprints should be directed to Mary E. Willmuth, Department of Medical Psychology, Medical Center Hospital of Vermont, Burlington, VT 05401.

PHOTO (BLACK & WHITE): Figure 1

PHOTO (BLACK & WHITE): Figure 2

PHOTO (BLACK & WHITE): Figure 3

PHOTO (BLACK & WHITE): Figure 4

PHOTO (BLACK & WHITE): Figure 5

PHOTO (BLACK & WHITE): Figure 6

PHOTO (BLACK & WHITE): Figure 7

PHOTO (BLACK & WHITE): Figure 8
REFERENCES

Geller, B., & Greydanus, D. E. (1979). Psychological management
of acute paraplegia in adolescence. Pediatrics, 63,
562-564.

Gordon, K. H. (1987). Psychiatric care for children with spinal
injuries. Pennsylvania Medicine, 90, 60-62.

Labarca, J. R. (1979). Communication through art therapy.
Perspectives in Psychiatric Care, 17, 118-124.

O'Neill, E. W. (1989). Art therapy with children with cancer.
Journal of the Association of Pediatric Oncology Nurses, 6,
36-37.

Walker, C. (1989). Use of art and play therapy in pediatric
oncology. Journal of Pediatric Oncology Nursing, 6,
121-126.

Wolf, J. M., Willmuth, M E., Gazda, T., & Watkins, A. (1985).
The role of art in the therapy of anorexia nervosa.
International Journal of Eating Disorders, 4, 185-200.

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By JOANNE E. EPPING and MARY E. WILLMUTH

JoAnne E. Epping is a doctoral student in clinical psychology at the University of Vermont. She has worked with individials in a variety of medical settings, including the rehabilitation unit at Medical Center Hospital of Vermont. Mary E. Willmuth, PhD, is a rehabilitation psychologist who works with adolescents and adults with disabilities and traumatic injuries.

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