هنر درمانی در یک واحد پیوند مغز استخوان: مطالعه موردی از جانباز جنگ ویتنام مبتلا به اختلال مغز استخوان

At this time in history, the medical world is beginning to accept holistic approaches to aid in the psychosocial treatment of its patients. This is particularly true for cancer patients. Art therapy is one such psychosocial intervention that provides many possibilities for healing for such patients. This case study examines the art therapy experience of one such patient, a 52-year-old male in medical isolation after having received stem cell transplantation (SCT) to treat myelofibrosis, a life-threatening illness. The patient was a Vietnam Veteran and had a history of alcohol abuse. This study examines how the patient’s history impacted his state of mind during hospitalization and isolation and how this was reflected in his artwork. Art therapy provided a means of examining this patient’s past traumas so that he could then move into examining and living in the present moment. It also provides an example of how art therapy moves beyond the means of art making as healing to the world of metaphor and mental imagery as healing agents in a therapeutic process.

As the medical world begins to accept a holistic approach to the treatment of individuals with physical disease, more psychosocial interventions are being offered to patients in the medical setting, particularly cancer patients. While cancer patients in general experience similar psychological issues and needs, many of their issues will be unique to their particular disease and mode of treatment. Stem cell transplantation (SCT) and bone marrow transplantation (BMT) are two modes of treatment that are similar in both physical procedure and psychosocial effects for the individuals who undergo them. Both procedures may be used to treat various blood disorders such as leukemia, Hodgkin’s disease, lymphoma, as well as diseases such as breast cancer and multiple myeloma (Andrykowski & McQuellon, 1998 and Andryknowski et al., 1999). Andryknowski et al. explain the physical procedure and psychosocial ramifications for SCT, Transplantation of hematopoietic stem cells obtained from bone marrow or blood is employed in the treatment of a variety of serious, life-threatening, primarily malignant diseases … Potential problems span the spectrum of QOL domains and represent a range of physical, functional, emotional, and social difficulties. In addition to the well known physical late effects of SCT, such as graft-versus-host disease, pulmonary problems, and rheumatoid disorders, problems with fatigue, sleep, sexual and cognitive function, and psychological and interpersonal adjustment have been identified. (Andryknowski et al., 1999, p. 1121). BMT is also a serious procedure with various ramifications for the individual undergoing the procedure. Andrykowski and McQuellon explain, Bone marrow transplantation (BMT) is a complex medical procedure in which blood cells … in bone marrow are infused into a patient following high-dose chemotherapy and/or radiotherapy. Because BMT is associated with life-threatening physical morbidity, lengthy convalescence, and social isolation, the potential for significant psychosocial morbidity is high. (Andrykowski & McQuellon, 1998, p. 289) While SCT and BMT are similar in nature, most of the research and literature in the field focuses on the psychosocial effects of BMT. Therefore, much of the research referenced in this article is related to BMT, however, it is widely accepted, and has been the author’s clinical experience, that the psychosocial ramifications for an individual undergoing SCT are similar to that of an individual undergoing BMT. Because of the serious nature of SCT and BMT, it has been found that with transplantation comes the potential for an increase in psychological distress such as anxiety and depression (Baker, Marcellus, Zabora, Polland, & Jodrey, 1997; Sasaki et al., 2000). Coping mechanisms, such as perceived personal control, have been correlated to psychosocial morbidity (Fife et al., 2000). While in isolation, the patient may have “severe side-effects of nausea, vomiting, and pain as a result of mucositis” (Gabriel et al., 2001, p. 114). The normal stay on the hospital floor for SCT patients and BMT patients ranges from four to six weeks, but if complications arise it can be longer. While the SCT and BMT experience is clearly a time of psychosocial distress, few sources have examined psychosocial interventions with this population. Irene Rosner David and Shereen Ilusorio wrote about their experience working with tuberculosis (TB) patients in isolation and stated “Patients benefit from the artistic expression of their emotions not only regarding the disease and prognosis, but also regarding the unique experience of isolation” (Rosner David & Ilusorio, 1995, p. 30). The main difference between the isolation experience for SCT or BMT patients and TB patients is that SCT and BMT patients are being protected against the germs others may give them while TB patients are being protected from giving germs to others. This needs to be kept in mind when you are working with patients in isolation as the psychological ramifications of the isolation experience differ. Gunter (2000) wrote about the use of art therapy with children undergoing BMT. But only one study has examined the use of art therapy with adult BMT patients in isolation (Gabriel et al., 2001). The work of Gabriel et al. (2001) indicates that art therapy with adult BMT patients in isolation “… can be used to fulfill a variety of needs: (a) to strengthen positive thoughts, (b) to resolve distressing emotional conflicts, (c) to deepen the awareness of existential and spiritual issues, and (d) to facilitate communication with relatives and friends” (p. 122). As a graduate art therapy intern working with adult SCT and BMT patients at a cancer hospital in New York City where the work of Gabriel et al. had taken place, I decided for my thesis to conduct a broader study examining the BMT psychosocial experience from the patients’ point of view (Greece, 2002). The purpose of this study was to explore what psychosocial interventions were appropriate for this population. Also important was to examine how art therapy should be approached when working with this population. A convenience sample (n=11) of adult BMT patients consisting of five men and six women were interviewed regarding their isolation experience. Four areas of psychosocial experience were examined: verbal interchange, activities, body-oriented care, and self-expression. It was found that 82% (n=9) of the sample stated a benefit from having someone to talk to, 73% (n=8) stated a benefit from having things to do, 54% (n=6) stated a benefit from body-oriented care, and 54% (n=6) stated a benefit from self-expressive outlets. This indicated that there are several psychosocial interventions applicable to this sample including art therapy. It was also found that art therapy sessions with this sample should be verbally oriented, passive in activity, mindful of the body, and expressive in nature ( Greece, 2002). The findings serve as a compliment to the findings of Gabriel et al. that art therapy with adult BMT patients in isolation can be an appropriate and useful intervention ( Gabriel et al., 2001). The particular case presented here is one example of how art therapy can be useful for an adult SCT or BMT patient in isolation. Mr. A’s art therapy experience provides insight into the complexity of the human psyche when faced with a life-threatening illness and shows how eloquently one’s psyche can display itself when given the opportunity to engage in the act of creation.

Art therapy offers the chronic and terminal patient many avenues for exploration, from the mind–body connection striving for peace and positive thinking to the psychoanalytic process of re-examining oneself and integrating their experiences into a new life framework. The process will be unique for each individual. The goal of individual art therapy with Mr. A was to provide psychosocial support to aid in coping with the experience of isolation and the ramifications of living with a life-threatening illness. This was achieved by providing consistent support through art therapy, which included the building of a therapeutic relationship between Mr. A and the art therapist and providing the opportunity to create and process artwork and verbalize relevant issues. Through art therapy Mr. A both verbally and non-verbally examined many facets of his character, which was shaped by his life experience. While his initial imagery (Fig. 1 and Fig. 2) was born out of his Vietnam experience and trauma, his later images (Fig. 3 and Fig. 4) were born out of his current experiences. By first verbally and visually working through some of his issues related to his trauma in Vietnam, Mr. A was able to visually and verbally delve into his current state of being. Art therapy helped Mr. A move fluently from re-examining past traumas through his artwork (Fig. 1 and Fig. 2) and the verbal processing of his artwork, to examining through his artwork the current state of his life in isolation (Fig. 3 and Fig. 4). Art therapy also provided Mr. A with a strengthened support system by providing consistent psychosocial support through the relationship with the art therapist. As well, the art therapy sessions provided an increased means of communication between Mr. A and the team of professionals that cared for him as the information was shared with the social worker and other appropriate personnel. By becoming aware of the information learned about Mr. A through the art therapy process, team members were better able to understand Mr. A and interpret his reactions and state of being throughout hospitalization. As an art therapist, I am able to gain a deeper knowledge of my clients through their artwork and use of metaphor, than through verbal interaction alone. This was the case with Mr. A as I described in detail in the “Clinical process” section. However, as is true with all forms of creative arts therapies, art therapy is not only about an individual revealing themselves to the art therapist through their artwork, it is about the individual communicating deeply with themselves as the unconscious reveals itself safely through the artwork. It is then through the processing of this inner communication that an individual begins to understand themselves clearer. Mr. A received many benefits from art therapy while hospitalized for his SCT, as stated earlier, which included an increased support system as well as an opportunity for self-expression and self-examination. However, there were limitations to Mr. A’s art therapy experience. The major limitation was that Mr. A was seen for art therapy on a short-term basis only. Because Mr. A was not given the opportunity to continue art therapy after being discharged from the hospital he was only able to scratch the surface of the many layers of psychological healing that long-term therapy can bring, particularly given the trauma he had experienced in his life. It is possible that Mr. A could have benefited more had his art therapy sessions continued after he was discharged from the hospital. In particular, he would have been able to continue to explore his current state of being which had only begun to happen during his hospitalization. There are also many other important issues, besides length of treatment, for therapists to realize when working with BMT patients in isolation. Therapists must remember that at times they may serve as a real object to the BMT patient, more so than with most populations. Nancy Postone (1998) states, “For cancer patients, the real relationship with the therapist in the present takes on particular importance as it provides a necessary anchor in the face of existential threat and fear of abandonment” (p. 420). Concerning countertransference with cancer patients, Postone reminds us, “The illness is a challenge to the therapist’s rescue fantasies and wish for omnipotence. ‘What can I do? What can I offer?’ are questions that often confront a therapist. Difficult feelings of loss and control, and those arising from becoming aware of one’s own vulnerability must be dealt with” (p. 420). In my clinical experience to date I have found that when you work consciously with as much information and as clear a mind as possible the countertransference issues can be used to the advantage of both the therapist and the patient. Mr. A recently returned to the hospital for a routine visit. Now, one year after his SCT, he is physically strong and doing quite well. He spoke to me at length about the realization that he had come so close to death and surprised just about everyone with his continued recovery. “The man upstairs,” he stated, as he pointed upwards and explained that this entity goes by many names such as nature, God, and Buddha, “is orchestrating his plan, we can’t control it.” Later in the conversation he explained that he had made a decision long ago that he was not going to give in to his disease. “Mind over matter” is very strong he told me. I realized as I walked away from our meeting that Mr. A was happy to be alive. I don’t credit this to his art therapy experience or even to the brilliant work of his medical team, but to Mr. A himself, a man having lived through many hard experiences and still reveling at the mysteries of life. Creative arts therapists throughout the world have the capacity to provide the opportunity for various levels of support to transplant patients in isolation. The experience of Mr. A is but one example of the power of art therapy to provide psychosocial support to those faced with life-threatening illness and medical isolation. The art therapy experience of Mr. A sheds light not only on how image making and the visual art process can aid in meeting the goals of individual art therapy, but how metaphors and mental imagery have the power to do the same.