Art Therapy during COVID-19 with a Deaf Client Diagnosed with Schizophrenia: A Case Report

Or Shalev ^*

1. University of Haifa, Haifa, Israel

* Correspondence: Or Shalev

Academic Editor: Noah Hass-Cohen

Special Issue: Expressive Arts Therapies during and in the Aftermath of the COVID-19 Pandemic

Received: April 28, 2023 | Accepted: July 02, 2023 | Published: July 11, 2023

OBM Integrative and Complementary Medicine 2023, Volume 8, Issue 3, doi:10.21926/obm.icm.2303028

Recommended citation: Shalev O. Art Therapy during COVID-19 with a Deaf Client Diagnosed with Schizophrenia: A Case Report. OBM Integrative and Complementary Medicine 2023; 8(3): 028; doi:10.21926/obm.icm.2303028.

© 2023 by the authors. This is an open access article distributed under the conditions of the Creative Commons by Attribution License, which permits unrestricted use, distribution, and reproduction in any medium or format, provided the original work is correctly cited.

1. Introduction

Art therapy is a mental health profession that utilizes artmaking, applied psychological theories and supportive psychotherapeutic relationships to promote self-exploration, communication, and healing [1]. This therapeutic approach benefits individuals with mental and physical disabilities, providing a safe and caring environment to explore their experiences and express their emotions [2,3].

Deafness is a varied biological, psychological, and social construct affecting millions worldwide. Most Deaf people have very little or no hearing, and often rely on sign language to communicate [4]. They also have a high probability of experiencing complex mental health issues and additional disability risk factors related to genetics, nerve function and environmental stressors [5,6,7,8].

Art therapy's visual language allows for the symbolic expression of feelings and thoughts, which can be an appropriate medium for those in the Deaf community, as they are primarily visually oriented. Therefore, art therapy allows them to connect internally and interpersonally [9,10,11]. It can also address the complex needs of individuals with comorbid physical and mental health conditions, offering symptom relief and a framework for expressing their unique challenges [12,13].

Schizophrenia has been found to have similar prevalence and symptoms among Deaf and hearing people. However, due to barriers in diagnosis and presentation, untreated psychosis may be prolonged among Deaf people [14,15]. Schizophrenia is a chronic mental illness that affects about one percent of the general population, usually with an onset in early adulthood. It is characterized by long-term impairments in social and occupational functioning [16,17]. A schizophrenia diagnosis includes positive symptoms, such as delusions and hallucinations; negative symptoms, such as apathy and social withdrawal; and cognitive symptoms, such as deficits in working memory, executive function, and processing speed [18].

A recent systematic review of art therapy for clients with mental illness showed that art therapy significantly positively affected adults' self-awareness, self-esteem, resilience and more [19]. As a profession originating in psychiatric hospitals, art therapy has been found by therapists and clients to be beneficial and meaningful for individuals with schizophrenia, as well as effective in symptom reduction [20,21,22]. Notably, art therapy's quality and results are greatly influenced by the quality of the therapeutic relationship and its dynamics.

Therapists' professional knowledge places them, socially and historically, in a position of power over their clients [23]. Modern approaches, however, see the therapist as an instrument of power, the distribution of which is up to the therapist and client. Together, they acquire knowledge about the client and construct meaning for the therapy [24,25]. Conversely, collaborative-based postmodern therapies oppose modern approaches and hold that the knowledge of the therapists, shaped by their social influences, carries an inherent element of power that influences the therapeutic alliance and cannot be ignored for the therapists to be accountable for them [26]. In art therapy, the client and their artwork are included when considering the ethics of power relations. Thus, McNiff [27] has emphasized the importance of respecting each individual's artistic expression in art therapy and supported treating both the artwork and the client with the same positivity, curiosity, and empathy. In addition, Kapitan [28] has stressed the need for collaboration between the art therapist's knowledge and the client's expertise regarding their priorities and cultural values. Accordingly, in art therapy relationships, the triangular relationships between the therapist, client, and artwork should also be considered, as they are related and interdependent [29]. The transference, countertransference and aesthetic transference relations between the client and the art therapist, and of both towards the artwork, are factors in art therapy that therapists must be aware of and work with [30,31]. In recent years, however, a global crisis turned the tables on reality as we know it, including therapy and its power dynamics.

In December 2019, Coronavirus (COVID-19) spread quickly worldwide, leading the World Health Organization (WHO) to declare a public health emergency of international concern on January 2020 and to characterize the outbreak as a pandemic on March 2020 [32]. By March 2020, Israel imposed the first lockdown on its population. Many services were closed to the public and moved to an online format where possible. Everyone was required to stay home, and a general feeling of uncertainty and danger was evident. The lack of stability and various quarantine mandates negatively affected people's mental health, increasing stress, anxiety, depression, PTSD symptoms, and more [33]. While health resources were limited, people with severe mental illness were especially vulnerable to the emotional effects of the global crisis [34]. In particular, the Deaf community faced unique challenges, including being unable to read lips while others wore face masks, which created a severe communication barrier [35].

COVID-19 also took its toll on health professionals' well-being as they were required to care for others while working under a great deal of stress and being subjected to the same health threat [36,37]. Shared traumatic reality is a concept that refers to therapists who are exposed to or work under the same threats as their clients [38]. Working in a shared traumatic reality can have negative and positive impacts on therapists, such as persistent mental distress, heightened empathy for clients, and a possibly renewed professional commitment [39,40] Previous research has suggested that therapists should strengthen their support systems and engage in self-care under such circumstances to avoid having their personal trauma narratives infringe on their clients' therapy [41]. Art can provide a safe outlet for stress and promote introspection through self-expression, especially in times of crisis [42,43]. Moreover, art therapy is a healthy method of self-care, and art therapists are known to use artmaking to help their clients and themselves [27,44]. While art therapists faced many challenges during the COVID-19 pandemic [45], this article explores a single case of art therapy [46], focusing on the therapeutic opportunity created by the shared traumatic experience. IRB approval and consents from the client and her guardian were obtained for this case report and its images.

2. Case Description

Leah (pseudonym) is a 60-year-old woman living in a hostel for people with mental illness in Israel. She is deaf with a severe speech impediment and has been diagnosed with schizophrenia. Although this is her condition, she did not self-identify as such during our sessions, only as a woman to be addressed as she\her. I (the author) am a 30-year-old art therapist, I also identify as a woman and my pronouns are she\her. I am an art therapist with 5 years of experience and was hired by Leah’s social worker who wanted Leah to see a psychotherapist every week. Our sessions were one hour long, once a week, and lasted for two and a half years. For each session, I brought art materials, laid them out for use, and collected them at the end of the session. In addition, at her request, I kept her artwork between sessions. No official psychotherapeutic sessions were offered in her hostel, so our sessions were paid for from her budget, with her guardian’s approval. The sessions were held at the apartment Leah shared with other residents in the hostel. There were times during our sessions when Leah had to leave for other commitments, such as receiving medical treatment, or the hostel staff that would come to the apartment show interest in her work. Other tenants would call me to help them with tasks or ask me to be their therapist. In this way, working in a place of residence differs from conducting psychotherapy in a private room. There was much more engagement with other people during the sessions and acknowledging them was also part of the work [47]. During Leah’s sessions, I kept her time as exclusive as possible, while also relating to the others engaging with us, making sure to include Leah in the conversation.

2.1 First Sessions: Getting to Know Each Other

When I entered Leah’s apartment for the first time, I was greeted by a potent smell of detergent, cigarettes, and feces. Later I learned that one of the residents wore diapers. Leah was waiting for me at the dining table. Her room was very tiny, so she preferred not to work there. She appeared pleasant and excited to see me. Although I do not speak sign language like her, we communicated through facial expressions and hand and body gestures. Since I had previously worked with psychiatric inpatients who did not speak Hebrew, I was used to this type of physical communication. I also brought her a sketchbook to allow her to create an ongoing, private space to express herself and for us to communicate. Through her writing, the first thing I learned about her was that she came from a religious Jewish background. As a secular Jewish therapist, it made me reflect on our differences. I wondered how these differences would manifest in our newly forged relationship.

During the initial sessions, Leah wanted to draw with markers and paint coloring pages. She was used to painting children's coloring pages brought to her by the hostel staff from craft stores. I brought her some at her request. However, it was important for me to choose those with appropriate content for her age, such as famous works of art, like the Mona Lisa, presented in Figure 1. She immediately recognized them and wrote to me about the artists who made them.

Figure 1 "Mona Lisa" coloring page.

Observing her, I saw that she worked slowly, carefully selecting colors. It seemed important to her that her work would be precise. The markers allowed her better control over her artwork, and she did not need to use force to create vibrant colors. Using markers is a typical activity for young children, so I was unsure how appropriate they were for Leah's therapy process. Due to her many years of mental illness and physical disabilities, it was challenging to discern her mature qualities. But I viewed her as a grown woman with life experience and an inner wealth that was yet to be expressed in our sessions.

2.2 Efforts to Refine Therapeutic Interventions

Although Leah felt comfortable using markers, her artwork remained flat and childish. She had also been painting coloring pages for years, satisfying her need to be held and contained in a safe space. Still, I was haunted by a deadly feeling due to the lack of liveliness in our interaction. Although she worked with enthusiasm, my presence felt unnecessary, and boredom overtook me. I looked for artwork to allow her to be more authentic and express her inner world. In my supervision sessions, I discussed my concerns about whether I was trying to satisfy my needs or being truly attentive to Leah. My supervisor and I agreed that asking Leah herself would allow me to meet her needs while also examining other possibilities of artistic expression.

When Leah drew freely, her work was small and had short and weak movements. She would get tired of it quickly and give up angrily. Whenever she had trouble drawing, she asked me to show her how to do it or do it for her. Figure 2 presents our drawings of a bell pepper Leah bought and wanted to draw.

Figure 2 Bell Peppers (Leah's drawing on the right).

Although I tried to match my work to her level, the gap between us was evident. I also noticed she did not make a connection between the object and the background as I did, which felt unrelated to her artistic abilities and more like an unconscious choice. She seemed to enjoy the shared activity but got frustrated that her work did not match mine. To strengthen her sense of competence, I brought stencils and rulers so she would have supportive tools. An example of a drawing she made using round stencils can be seen in Figure 3. Leah was pleased at first, and her artwork had a significant presence on the page, as she had wanted. However, she became exhausted quickly and needed long breaks. Although she was excited when I brought her new art materials, she still could not express herself as she desired, and we both felt frustrated.

Figure 3 Drawing with stencils.

Leah's inner world became more evident when she added words to her artwork, for instance, when she chose magazine pictures. In Figure 4, Leah chose a picture of a herd of elephants titled "the last hope," and below, in small writing, was the question of their survival against man and nature. In this way, Leah may have indicated her difficulties during her lifetime. As I viewed the image, I also saw a hint of hope in the ability to be together as a herd. I was moved by Leah's desire for a relationship and felt empathy for her.

Figure 4 "The Last Hope."

When Leah was tired from drawing, painting or making collages, she turned to writing. Consequently, a stream of associative and disorganized content would burst out, leaving me little room to respond. She described daily events mixed with memories from her childhood. She also described experiencing intrusiveness, aggression, and neglect in her past and present. In detailing the injections and medications she regularly received, she also attributed malicious intent to the nurses. Additionally, she described the physical, sexual, and emotional abuse she experienced as a young girl. At such times I noticed that I lost my focus, became dissociated, and felt tired. I also noticed that my presence drew her attention to the things she did not have, which she mentioned in her writing: youth, a romantic relationship, and freedom. It felt as if our differences were heavily present between us. As determined as I was to strengthen our therapeutic relationship and empower Leah, my mind felt cluttered, and I struggled to think clearly.

2.3 COVID-19 Outbreak: Separation and Reconnection

The COVID-19 outbreak forced a month-long break in our sessions, as only essential staff members were allowed in the hostel. During the first lockdown, I engaged in artmaking to gather the strength to face the new threatening reality and regulate my emotions. Embroidery gave me a means of expressing aggression, regulating myself through repetitive actions and creating something with aesthetic value. I thought of Leah. Her age and social background led me to believe that she most likely had experience with embroidery and might connect to this kind of artwork.

As our sessions resumed, Leah showed signs of distress and emotional overload. I would come to the hostel for our sessions to find her asleep or that she had gone out. When we did meet, she filled our sessions with writing, focusing on her workplace in the sheltered workshop where shifts had become irregular and the nurses in the hostel who administered injections. My heart went out to her during this time of uncertainty and confusion. As a result of her inability to comprehend the complex situation, she manifested her panic through rage and detachment. I wanted to reach out and comfort her, but we encountered a new obstacle-we had to wear face masks. This took away one of our main sources of emotional communication-the ability to use facial expressions and lip reading. Leah kept asking me to remove my mask. I was torn between my desire to keep her and myself safe from the COVID-19 virus and wanting to communicate with her and facilitate our reconnection. It took us a few weeks to adjust to the new setting. My regular return and empathic reflections on her confusion gradually re-established our relationship. We also began writing the date of the next meeting in her diary. She would write, and I would add a small drawing next to it, like a flower or a butterfly. It was something from me that she could keep until our next session.

Again, Leah began to meet with me on time and even reduced her writing so that she could make art. I then proposed using a new material embroidery. Leah seemed enthusiastic and wrote that her mother had taught her embroidery. I brought fabrics, threads, needles, and a hoop to the next session. She chose her threads and asked me to cut them for her. When she had trouble threading the needle, she gladly accepted my help. For several consecutive sessions, Leah immersed herself in the embroidery process. It seemed that there was a certain stitch that she knew well and used repeatedly. It became apparent that she experienced a sense of control and confidence when engaging in the familiar and loved activity. These sessions fascinated me and kept me focused. The small, delicate creations she made captivated me, and above all, her patience and meticulous determination filled the contours she first created. One of her works is presented in Figure 5. The staff and other residents were also amazed by her abilities and what she created. One staff member even brought her a frame for her finished embroidery. As a result of the artwork, Leah gained a new appreciation for her abilities. She was delighted by the embroidery, and I felt it honored her life experiences.

Figure 5 Embroidery during art therapy sessions.

My role also changed. Instead of being some sort of art teacher, who represented an ideal she could not achieve, I became her assistant or an attentive mother, allowing her creative flow to flourish. She told me what colors and lengths of the thread she wanted, and I threaded the needle or loosened the knots that formed. We shared a very pleasant intimacy at these moments. We continued meeting for another year before personal circumstances required that I end our sessions.

2.4 Parting: Concerns and an Exciting Discovery

Upon learning that her therapy was ending, Leah expressed her sadness, mainly in writing. In one of the sessions dedicated to our parting, she chose a striking image from a magazine that spoke louder than words. It was a self-portrait of an elderly woman, looking straight at the viewer, with the words "who remembers, who knows, the forgotten painter" underneath, to which she added two flowers that she did not finish the drawing. The entire artwork can be seen in Figure 6.

Figure 6 "Who remembers, who knows, the forgotten painter."

I was reluctant to leave her and wondered whether she would continue her embroidery after I left. I gave her the embroidery materials as a farewell gift at her request. However, I was also worried that without my help, she would be unable to continue working.

As therapists, we carry our clients in our hearts and minds but rarely know what happens to them after we part. Nevertheless, in this case, I had a pleasant surprise. Following my request for permission to publish the case, Leah sent me photographs of the embroidery she made after the therapy sessions ended. I was overjoyed to receive the picture presented in Figure 7. I was intrigued by the abstract images and the narrative they hid. Furthermore, I hoped it meant she was not alone in doing what she loves.

Figure 7 Embroidery after art therapy sessions ended.

3. Discussion

This case report described a two-and-a-half-year art therapy process and the shifts in the therapeutic power relations before and after the outbreak of the COVID-19 pandemic. It was a bumpy road to finding the right therapeutic relationship balance. First, the therapy sessions were not held in a private room in the clinic. Instead, they took place in the client's living room in her apartment, in front of other hostel residents and staff members. This type of setting is unfamiliar to most clinicians and can seem intimidating. For example, difficulties arose in establishing a holding environment [48] due to unplanned interactions with others and even the foul odor at the beginning of the therapy meetings, which involves a built-in element of mutual anxiety [49]. Such challenges required me to navigate how to get to know Leah both in and out of her living space. However, the benefits for Leah were prominent, as her caregivers and I could admire her artwork together and discuss her progress with her. This corresponds to a previous study on home-based art therapy for older adults with mental illness, which demonstrated that the presence and involvement of a caregiver during art therapy benefits both the client and the caregiver [47].

In the early stages of therapy, Leah needed a framework to express herself. For her, coloring pages were familiar and safe, although they kept her authentic expression limited and childish. Former research has encouraged art therapists to consider using coloring as an entryway to art therapy in which more spontaneous, creative, and self-expressive transformative change can occur [50]. When we were beginning to become acquainted, it was appropriate for me to respect the instruments she was familiar with and knew how to use, as this allowed me to get to know her through them [51]. Despite Leah's interest in our meetings and apparent desire for connection, upon realizing there was, in Ogden's [52] terms, ‘deadness’ in the transference/countertransference relationship, I set out to find new ways to reach Leah.

Alvarez's [53] ‘Live Company’ and its derivative, ‘Reclaiming Function,’ are concepts describing the therapist's engagement in therapy as they reach out and actively invite the client to interact. By refusing to cooperate with the client's rigidity, Alvarez transferred her liveliness onto her clients, which helped them develop their strength. In art therapy, art materials are carefully selected according to the client's needs and regarded as active partners in the therapy process [54,55]. As her art therapist, I offered different art materials and interventions to actively search for her authentic spark, mainly when I felt emptiness and despair. However, I soon realized the conventional materials I brought, although of high quality [56], did not fit their purpose and created frustration and self-criticism instead of creativity and self-discovery [57]. Compared to the coloring pages and markers, watercolors were too uncontrollable and anxiety provoking for Leah, consistent with the theoretical literature regarding annihilation anxieties among those experiencing psychosis [58]. Furthermore, our joint paintings highlighted the differences between us without words, emphasizing Leah's lack of integration compared to mine (e.g., see Figure 2 and the difference in each bell pepper's integration with the background) and making our therapeutic relationship tense [59].

The importance of art therapists being familiar with the art materials they offer clients, whether to assist with using them or understand their diagnostic value, has been discussed extensively [27,60]. However, being responsible for choosing and bringing in the art materials and looking after the art products, positioned me as the all-knowing powerful "provider," the one in control. Thus, Leah was positioned as a passive receiver instead of an active mutual partner [28]. Nevertheless, it did not feel like a beneficial Regression to Dependence in the context of therapeutic holding [48], but rather a malignant regression aimed at maintaining gratification [61].

A previous study discussing the issue of control in home-based therapy found that clients perceived their therapists as experts and expected them to have complete control over the therapy sessions [62]. Despite Leah's pleasure in having me lead the therapy, her growing frustration signaled that the hierarchical dynamic that had begun to form did not benefit her. I became concerned with finding a way to overcome this. However, our relationship went through an unexpected upheaval due to the global pandemic.

The world's population, Leah and myself included, was in a state of helplessness at the beginning of the pandemic. It has been suggested that at the base of all COVID-19-related mental health conditions, such as encompassing anxiety, acute stress, depression and many more, lies fear – one of the most basic human emotions [63]. Increasing the locus of control is one of the first steps to developing competence and emotional balance in crises [64]. This may occur when one engages in a familiar daily self-care activity, such as creating art [63]. By previous research suggesting that art can be a facilitating tool for therapists in stressful situations [65], I found calm in embroidery. I was introduced firsthand to this craft's aesthetic value and regulating meditative qualities [66]. Thinking about Leah arose unexpectedly, like an "aha" moment. While it was not my intention to make response art to our therapeutic relations, through embroidery, I was able to experience an emotional process that echoed what I was searching for Leah [67].

Meanwhile, Leah's daily routine changed dramatically following the COVID-19 outbreak. Like many in the Deaf community, wearing masks restricted her ability to receive information and communicate [35]. Radical changes were made to her working hours, increased restrictions regarding traveling outside the hostel and more. To her, these changes and restrictions seemed unclear and surprising and, therefore, threatening. This was a common response among people with chronic mental illnesses during COVID-19, due to the difficulty in grasping and understanding what was happening [68].

After we resumed our sessions, Leah's withdrawal was evident, but the embroidery brought her joy and renewed vitality. In a novel study on art therapy and embroidery, the researchers found that the clients' choice to create unstructured (freestyle) embroidery could reflect their emotional states and may offer a sense of release in the face of restrictive experiences, such as the rigid patterns imposed during psychiatric hospitalizations [69]. It can be assumed that Leah was enjoying freestyle embroidery as a release from COVID-19's restrictive and forced patterns. By creating her boundaries in embroidery – making outlines for her freestyle work in which she was contained – she regained control differently than the flat, fast work produced by markers and the premade outlines of the coloring page. The stitching also brought a slower rhythm and deep meditating quality to her work. In addition, crafts such as sewing and embroidery promote mental processes and evoke childhood sensory and emotional experiences [70]. As Leah embroidered, she recalled pleasant childhood memories of her mother, felt pride, and received recognition from others. Respectively, we developed a new and pleasant intimacy, and I became a benevolent and supportive partner in her process.

Due to the complex nature of this case, I was required to step out of my comfort zone and be active and creative in how I was trying to reach my client. This was important in creating our initial connection and trust [71]. However, the true shift in our therapeutic relations occurred when I was forced, by a frightening global reality, to step down from my omnipotent position. While we were both subjected to the same circumstances, I was able to reconnect with Leah through my personal need for support and to process using art [63]. Returning to my roots, to my artwork, was essential in creating movement in how I positioned myself, thus, reconstructing the therapeutic power relationships in a way that allowed Leah to own her ‘aliveness’ in the art therapy sessions, which carried on after our sessions ended.

4. Conclusions

This case report provides a new understanding of the importance of the art therapists' artmaking as a facilitation tool and a way to reconnect with clients during stressful times. I hope this case report will facilitate further research in art therapy when working in unusual times and settings.

Acknowledgments

I would like to thank my supervisor Moran Talmor-Krieger, who guided me throughout Leah's therapy and this case report, as well as the psychologist Tom Livni, for his theoretical contributions.

Author Contributions

The author did all the research work of this study.

Funding

This case report did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Competing Interests

The author has declared that no competing interests exist.