Psychosocial, symptomatic and diagnostic changes with long-term psychodynamic art psychotherapy for personality disorders

Psychosocial, symptomatic and diagnostic changes with long-term psychodynamic art psychotherapy for personality disorders

The Arts in Psychotherapy 41 (2014) 375–385 Contents lists available at ScienceDirect The Arts in Psychotherapy Psychosocial, symptomatic and diagn...

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The Arts in Psychotherapy 41 (2014) 375–385

Contents lists available at ScienceDirect

The Arts in Psychotherapy

Psychosocial, symptomatic and diagnostic changes with long-term psychodynamic art psychotherapy for personality disorders Nurhan Eren, PhD a,∗ , Nazan Emil Ö˘günc¸, PhD a , Vehbi Keser, MD b , Sevda Bıkmaz, MD c , Do˘gan S¸ahin, MD a , Bilgin Saydam, MD a a

Social Psychiatry Service, Department of Psychiatry, Istanbul Faculty of Medicine, Istanbul University, Turkey Istanbul, Turkey c Department of Psychology, Halic University, Istanbul, Turkey b

a r t i c l e

i n f o

Article history: Available online 23 June 2014 Keywords: Personality disorders Psychodynamic art psychotherapy Long-term psychotherapy Changes

a b s t r a c t In this study, we aimed to investigate the changes in the beginning and termination phases of psychotherapy in terms of psychosocial, symptomatic, diagnostic and personality qualities in patients with personality disorders receiving long term, individual psychodynamic art psychotherapy. This study was conducted with 17 patients at the Istanbul Medical Faculty, Department of Psychiatry. Psychosocial and clinical data were collected with a Personal Information Questionnaire, MMPI and DSM-III-R. The overall functioning (GAF) of the patients significantly increased (General: z = −3.631, p < .001), (highest level: z = −3.626, p < .001). There were statistically significant decreases in alcohol use (z = −2.45, p < .05), suicidal ideation (z = −3.00, p < .01), impulsive behaviors (z = −3.74, p < .001), self-mutilative behaviors (z = −2.24, p < .05), psychotic symptoms (z = −2.00, p < .05) and psychotropic medication use (z = −2.71, p < .01) at the termination phase. This study demonstrates that in the treatment of personality disorders, long-term psychodynamic artwork is beneficial and drawing is a good container that allows working through in psychotherapy. © 2014 Elsevier Ltd. All rights reserved.


Treatment of personality disorders

Individuals with personality disorders (PD) display pervasive multiple symptoms and frequent psychosocial crises. They experience difficulties with regard to affect and impulse control and have serious long-term interpersonal relationships and adaptation issues. Those conditions create coercive transference issues in the psychotherapy relationship and continuance of treatment is difficult; frequent dropouts occur. These patients have pathologically accommodated to their chronic relationship patterns and established secondary gains. They usually seek psychiatric treatment during a moment of crisis and tend to terminate treatment just after the crisis has ceased. Their personal difficulties and long term deterioration of their functionality have been emphasized in various studies (Gunderson & Links, 2008; Kernberg, 1984; Perry, 1993).

The conviction that PD are untreatable had begun to change with the increasing number of clinical practices (Bateman & Tyrer, 2004; Clarkin, Levy, & Schiavi, 2005; Fonagy, Roth, & Higgitt, 2005; Gunderson et al., 2011; Waldinger, 1987; Zanarini, Frankenburg, Hennen, Reich, & Silk, 2004). The number of clinical research studies is increasing in the field of psychodynamic psychotherapy. The most widespread and common hypotheses claim that the primary treatment for PD is psychotherapy; however, it is not easy to assess this process and application of randomized controlled studies are challenging (Bateman & Tyrer, 2004; Clarkin et al., 2005; Narud, Mykletun, & Dahl, 2005; Perry, Banon, & Ianni, 1999; Perry, 1993; Thormählen, Weinryb, Norén, Vinnars, & BågedahlStrindlund, 2003; Vinnars, Thormählen, Gallop, Norén, & Barbe, 2009). The following difficulties are among the most challenging: the high comorbidity of PD with Axis I and Axis II disorders, the presence of an ever-changing personality state because of rapid affective shifts, the need to observe the patient, preferably for one year, to recommend suitable treatment and the development of extremely intense transference; the counter-transference reactions in psychotherapy and the transformation of those reactions to acting out behaviors jeopardize the tolerability and sustainability

∗ Corresponding author at: Department of Psychiatry, Istanbul Faculty of Medicine, Istanbul University, Capa, Istanbul 34390, Turkey. Tel.: +90 532 7779607. E-mail address: [email protected] (N. Eren). 0197-4556/© 2014 Elsevier Ltd. All rights reserved.


N. Eren et al. / The Arts in Psychotherapy 41 (2014) 375–385

of the psychotherapy process and might result in the high frequency of drop outs (Abbass, Town, & Driessen, 2011; Ingenhoven, Duivenvoorden, Passchier, & Brink, 2012; Skodol et al., 2005; Zanarini et al., 2004). In addition, disintegration in the personality structure requires very complex interventions because of its resultant self-directed destructiveness, and difficulties with interpretation of the interventions are indicated. The results of studies, despite their limited number, indicate that in the psychological treatment of PD, numerous psychotherapy methods ranging from psychodynamic to cognitive-behavioral approaches are utilized and new methods are being developed (Clarkin et al., 2005; Fonagy et al., 2005; Gunderson & Links, 2008; Kernberg, 1984; Narud et al., 2005; Neacsiu, Rizvi, & Linehan, 2010; Stone, 2006; Yeomans, Selzer, & Clarkin, 1993). Most of the studies concern borderline PD (Choi-Kain, Zanarini, Frankenburg, Fitzmaurice, & Reich, 2010; Gabbard, 2001; Gunderson et al., 2011; Meares, Stevenson, & Comerford, 1999; Stevenson & Meares, 1992; Yeomans et al., 1993). The difficulties experienced in PD (and especially in cluster B PD) in terms of relationships, are rapidly and tumultuously transferred to difficulties in the psychotherapy relationship (Kraus & Reynolds, 2001; Meares et al., 1999). This situation enables and complicates the psychotherapy procedure. Numerous psychotherapy methods have been developed for the treatment of those patients consisting of approaches such as supportive, expressive and psychodynamic psychotherapy, which clarifies the interpersonal problems in the patient’s life with a here and now approach against primitive defenses and dialectical interpersonal psychotherapy (Clarkin et al., 2005; Kernberg, 1984; McCray & King, 2003; Neacsiu et al., 2010; Vinnars et al., 2009; Woeller & Tress, 2005). There are also approaches that focus on maintaining the framework of therapy and protecting and providing the sustainability of therapy by developing a contract and improving distorted self and object relations by focusing on the transference relationship (Waldinger, 1987; Yeomans, Selzer, & Clarkin, 1992). Studies related to the use of art psychotherapy and correcting maladaptive behaviors within a group or therapeutic environment while working with severe PD also exist in the literature (Eren, Özdemir, Ö˘günc¸, & Saydam, 2000; Johns & Karterud, 2004; Lamont, Brunero, & Sutton, 2009; Robbins, 1994).

Psychodynamic art psychotherapy In this section, brief information is provided about the psychotherapy method that was used for the study. The psychodynamic art psychotherapy model has been developed from psychoanalytic theory, developmental psychology and the object relations theory. The main foundation of this model depends on the theory that externalization or projection of an internal state as a work of art, transforms the internal state into a healthier form and re-internalization of the product by the patient (Johnson, 1998). Essentially, art psychotherapy relies on transformation of the internalized self and objective representations of primitive drives and fantasies into concrete forms by means of artistic items. Through the medium of art, internal mental experiences turn into external representations. In this way, a concrete product comes into existence, which corresponds to the primary figures that are identical to the repressed primitive themes. Projection is seen as the identifier of artistic expression, suggesting a causal process connecting art and the psyche and as the connecting process after the creation of artwork, in which it undertakes personal meanings (Johnson, 1998; McMurray & Mirman, 2001). One of the main factors in whether the patient remains in psychotherapy or not is the provision of an environment of security, safety, calmness, containment of affections and the opportunity to

regenerate the patient’s potential for development (such as the containment defined as an experienced state, as in Winnicott’s, 1971 “holding”, Bion’s, 1961 concept of “container”, Bick’s, 1968 and “boundary forming skin”). Especially in the psychotherapy of severe PD, when this need is not met, it becomes more difficult for the patient to remain in therapy. According to Killick (1997), the environment of analytical art therapy serves the function of a containing object for the nonintegrated mental state of the patient. According to Schaverien (1991), “the effects of painting are spatial and temporal, substantial and imaginary. During the therapeutic relationship and even after the relationship terminates, those effects can subsist and they provide a secure place to experience and evaluate the world of objects”. (p.103). Seth-Smith (1997) emphasized that the relationship between the painting and the creator of the piece goes through stages. Those stages follow a transformation process from being undifferentiated to becoming an object other than the self. This point of view is helpful in understanding the process of construing and internalizing the conscious and unconscious projections of disintegrated parts of the patient’s personality by observing from the outside. Artwork helps to develop and extend the space that Winnicott (1971) defines as the “transitional space”. It provides a bridge between objective and subjective reality. This way, the incompatible self and the object representations of the patient could be projected, held and remain integrated while generating less anxiety, and by consolidation of the transforming and reparative interventions, they could be internalized. The pictorial/symbolic content originating from the unconscious primary thinking process is transformed into a secondary thinking process within the relationship between the therapist and the patient (Killick, 1997; Lewis & Langer, 1994). The use of art psychotherapy for severe PD serves as a very beneficial tool, which facilitates the process of holding the patient in therapy (Eren et al., 2000; Lamont et al., 2009; Robbins, 1994).

Aim In this study, we aimed to investigate the psychosocial and personality factors and the symptomatic and diagnostic changes in patients diagnosed with PD in the beginning and termination phases of long-term, personal psychodynamic art psychotherapy.

Ethical considerations All of the steps and the treatment method were explained to the patients involved in the study, and their written consent to use the data and drawings was given

Methods Participants In this study, 17 patients who were involved in individual psychodynamic art psychotherapy in the Social Psychiatry Service (SPS), which is the PD unit of the Istanbul University, Istanbul Medical Faculty Department of Psychiatry between the years of 1997 and 2012 were evaluated. The changes in the 17 patients who remained in therapy during a time period of 4–10 years were evaluated. The patients who had a diagnosis of PD, were referred to the SPS by the general outpatient clinic and were recommended for individual art psychotherapy after psychiatric evaluation in the SPS were included in the study.

N. Eren et al. / The Arts in Psychotherapy 41 (2014) 375–385

Procedure The psychotherapist conducted a preliminary interview session with every patient referred to art psychotherapy after the evaluations. During this interview, the patients’ motivation, expectations, possible difficulties and the psychotherapy method were discussed; verbal contracts were established on issues related to the frequency of the sessions, duration, continuity and framework. Written consent was obtained from the patient concerning not leaving therapy without notice and for the scientific use of data obtained during the process of psychotherapy based on the condition that personal information is confidential. The frequency of the psychotherapy sessions with different patients varied between one to three times a week according to the severity of psychopathology, and the medical follow up interviews were conducted with a psychiatrist on the basis of the frequency of need (from one week to three months). The psychotherapist was supervised once a week by a psychotherapist experienced in psychodynamic psychotherapy. In addition to the individual supervision, the psychotherapeutic, psychiatric and psycho-social processes of all of the patients were discussed and the issues related to treatment and processes were addressed in a weekly group supervision session attended by all of the SPS team members. Art psychotherapy process During the time period when this study was conducted there were no art psychotherapists in Turkey. Despite the important developments in creative art psychotherapies in the recent years, it is not defined as a profession within the mental health team and there is still no art psychotherapist employed in the clinic where this study was carried out. Psychotherapy was conducted with an expressive art therapy approach by a nurse psychotherapist experienced in psychodynamic art psychotherapy and individual psychotherapy based on the object relations model. Besides the psychodynamic psychotherapy education, the psychotherapist in this study used psychodynamic art psychotherapy with severe mental disorders for the past 20 years. She has attended painting classes in the Mimar Sinan Fine Arts Academy for six months, worked in an artist’s studio in order to acquire experience with painting techniques and use of art material and attended various seminars and courses in Turkey on art psychotherapy and creativity. She has consulted with a supervisor who is experienced in art psychotherapies from her work abroad. Art psychotherapy sessions were carried out in a broad room where one side consists of a table and art materials and the other side of armchairs. Sessions last 60 min and typically divided into three parts. During the first part lasting 5–10 min, there was an introduction to the session and warm up, in the second part sensational and perceptional deepening and spontaneous creative artwork took place and the last 15 min was devoted to looking at the artwork from outside, sharing about the artwork and clarification, confrontation and interpretation when necessary. How the sessions will be carried out was set by the therapist in a semi-structured way, but the artwork was created first by the patient with the use of improvisation and then through the interaction with the therapist. How the sessions proceed was initially planned by the therapist in a semi-structured fashion, however they developed in an original and improvisational way first by the initiative of the patient and then in interaction with the therapist. The kind of artwork that will be created in the session was set forth by what the patient brings to the session that day (subjects effecting the patient, feelings, dreams, transferential processes, the way s/he perceives himself and others, fears, longings, conflicts and resistances, etc.) by working in depth with the therapist.


In our study, drawing/painting is a tool for the real world and the substantial transference relationship between the patient and the therapist. Artistic material is a medium for working with the patient’s associations related to his/her own life and the interpretation of the symbolic material transferred to the painting. The psychotherapy process consists of transformative and reparative therapeutic interventions by the psychotherapist whereas the patient creates the art material alone or with the therapist within the session. The process is conducted in the form of spontaneous or structured expressive work, depending on the patient’s ego strength and level of regression, working on his/her own or from time to time with the participation of the therapist. Working with drawing/painting was used in every session with all of the patients during the first two years of the psychotherapy process. As verbal communication improved, the interviews have been conducted mostly face to face. The criteria for the transition from artwork to verbal therapy are: polarized self and that integration and interpretation of object projections is sufficiently conducted on artwork, that primitive defenses reached a certain level of maturity and observation that acting-out reactions decreased, the patient can focus on verbal interactions and his/her ability to express oneself verbally has developed. After those criteria are reached, at the end of the second year, during which time the form of communication was mostly verbal, the artistic symbols created during the psychotherapy process during the first two years were interpreted as recalled memories of the patient’s personal process and the relational past with the therapist. Working with art continued at some sessions after two years. Instruments With a Personal Information Questionnaire developed by the researcher, the demographic information, the clinical symptoms and their prevalence and the psychosocial properties were obtained in the beginning and after the termination of psychotherapy. The information was collected in face-to-face interviews with the patients and from the patient files. The data were recorded using the clinical reports of the SPS professionals, other than the psychotherapist, who take part in the treatment of the patient The diagnostic, psychometric and psychodynamic assessments were conducted by different professionals working in the SPS with interviews lasting for 9–10 sessions. The diagnostic assessment was completed by two psychiatrists working in the SPS at the beginning and end of psychotherapy, according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IIIR) by evaluating the diagnostic criteria of Axes I, II and V (GAF) (APA, 1987). DSM diagnostic system, which contains five axes, evaluates psychiatric clinical diagnoses in Axis I. Axis II consists of assessment of PD within Cluster A (Odd; Paranoid, Schizoid and Schizotypal PD), Cluster B (Dramatic; Antisocial, Borderline, Histrionic, Narcissistic PD) and Cluster C (Anxious; Avoidant, Dependent, Obsessive-Compulsive, Passive-Aggressive PD). In Axis V, the Global Assessment of Functioning Scale (GAF) is used to assess the levels of functional impairment due to Axis I and Axis II disorders. To evaluate the personality features and psychopathology, the Minnesota Multiphasic Personality Inventory (MMPI) was used. The original MMPI was developed in 1943 (Hathaway & McKinley, 1943) in order to identify personal, social, and behavioral problems in psychiatric patients. Over time it became a widely used personality test in the mental health field. The inventory is a useful guide for identification of problems, diagnosis and treatment planning. MMPI consists of three validity scales which are as follows: L, F, K and 10 clinical scales which are as follows:


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Table 1 Socio-demographic properties at the beginning and termination phase of psychotherapy. Socio-demographic properties n: 17 Marital status Married Divorced Single Living with Spouse and child Mother–father Dorm Alone Educational level Elementary/middle High school/associate degree Undergraduate degree or higher Occupation None Skilled workers Self-employment Student Employment status Unemployed due to his/her problems Unemployed due to other reasons Employed Current educational status Left education due to problems Graduate/not a student Continues to study Decrease in occupational/academic success No Yes: low level Yes: marked level Income status Low Moderate Good Very good How does he/she earn a living? Self sufficient Partially dependent on another Completely dependent on another

Beginning phase f

Termination phase %



3 1 13

17.6 5.9 76.5

5 1 11

29.4 5.9 64.7

3 13 1 0

17.7 76.5 5.9 0

4 8 0 5

23.6 47.2 0 29.5

5 10 2

29.4 59.0 11.8

4 3 10

23.6 17.7 59.0

2 6 2 7

11.8 35.2 11.8 41.2

2 2 11 2

11.8 11.8 64.7 11.8

5 3 9

29.4 17.6 52.9

1 1 15

5.9 5.9 88.2

3 8 6

17.6 47.2 35.2

0 16 1

0 94.1 5.9

0 2 15

0 11.8 88.2

15 1 1

88.2 5.9 5.9

6 8 2 1

35.3 47.1 11.8 5.9

2 6 8 1

11.8 35.2 47.1 5.9

3 10 4

17.6 59.0 23.6

15 1 1

88.2 5.9 5.9

hypochondriasis (Hs), depression (D), hysteria (Hy), psychopathic deviate (Pd), masculinity-femininity (Mf), paranoia (Pa), psychasthenia (Py), schizophrenia (Sc), mania (M) and social introversion (Si). The reliability and validity study of the Turkish version of MMPI used in this study was conducted in 1981 (Savasır, 1981). The MMPI was administered at the beginning and after the termination of psychotherapy by a clinical psychologist. Data analysis The statistical analyses were conducted with SPSS software. Considering the small sample size and the multiple variables, we used descriptive statistics, the median, the standard deviation, in within subjects pre- and post-test comparisons the non-parametric Wilcoxon signed ranks test was used and between groups comparisons were carried out with Mann–Whitney U test. Results Psychosocial and clinical data Seventy-one percent (n: 12) of the patients who participated in the study were female, and 29% (n: 5) were male. At the beginning of the psychotherapy process, the mean age was 28.06 ± 7.03 years (min 20, max 43). In Table 1, the frequencies and percentiles of sociodemographic and psychosocial data obtained in the beginning

and after termination of psychotherapy are shown. According to these data, at the beginning of psychotherapy, 47.1% of the patients were unemployed, and only 17.6% could earn their living; 12% experienced a minor decrease, and 88% experienced a major decrease in their work and school success. At the end of psychotherapy, no decrease in work or school success was observed in 88.2% of the patients. The frequencies and percentiles of clinical symptoms in the patients, as identified by the clinician at the beginning and at the termination phase of psychotherapy are shown in Table 2. In the beginning phase, 23.5% of the patients had rare/social alcohol use, 29.4% had intermittent/recreational alcohol use and 17.6% had substance abuse. In addition, 17.6% of the patients had rare and 35% had frequent/repeating suicidal ideation, whereas 18% had rare and 6% had frequent/repeating suicidal attempts. Of the patients, 47% had rare and 35% had frequent/repeating impulsive behaviors, and 12% had rare and 18% had frequent/repeating self-mutilative behaviors. Of the patients, 30% experienced psychotic symptoms such as derealization and paranoid ideation. Before psychotherapy, one person had had a prior psychiatric hospitalization, and 6.5% of the patients were using psychotropic medication when they started psychotherapy. When the clinical symptoms in the beginning and the termination phase are compared with the Wilcoxon signed rank test, there were statistically significant decreases in alcohol use (z = −2.45, p < .05), suicidal ideation (z = −3.00, p < .01), impulsive behaviors

N. Eren et al. / The Arts in Psychotherapy 41 (2014) 375–385


Table 2 Clinical symptoms peculiar to personality disorders, hospitalization and use of psychotropics at the beginning and termination phases of psychotherapy. Clinical symptoms n: 17

Beginning phase f

Suicidal thought 3 Yes: rarely 6 Yes: frequent/repetitive 8 No Suicidal attempt 3 Yes: rarely Yes: frequent/repetitive 1 No 13 Alcohol use Yes: seldom/social 4 Yes Intermittent/reactive 5 Yok 8 Substance use Yes 3 No 14 Impulsive behaviors Yes: rarely 8 Yes: frequent/repetitive 6 No 3 Self-mutilative behaviors Yes: rarely 2 Yes: frequent/repetitive 3 No 12 Psychotic symptoms (partial loss of the ability to evaluate reality, paranoid ideas, etc.) 5 Yes 12 No Hospitalization 1 Yes No 16 Use of psychotropics Yes 13 4 No

(z = −3.74, p < .001), self-mutilative behaviors (z = −2.24, p < .05) and psychotic symptoms (z = −2.00, p < .05). The frequency of psychotropic medication use had decreased significantly (z = −2.71, p < .01) at the termination phase. Diagnosis, level of functionality (GAF) and continuance of psychotherapy In Table 3, the patients’ Axis I and Axis II diagnoses, according to the DSM-III-R criteria, in the beginning and after the termination phases, age at onset of treatment, gender, patients’ initials, the patients’ level of functionality, the duration of psychotherapy and the style of the termination of psychotherapy could be observed. The patients participating in the study most frequently had a diagnosis of major depressive disorder in Axis I (82.4%), and one third had an additional comorbid diagnosis. In Axis II, in the first three ranks, 47.1% of the patients had borderline, 35.3% had narcissistic and 29.4% had histrionic PD diagnoses; 82.4% had an additional comorbid diagnosis for a PD, and 35% had a diagnosis for a third comorbid PD. At the termination phase of psychotherapy, one person received a diagnosis of dysthymia in Axis I, whereas the others did not receive a diagnosis. In Axis II, one person received a diagnosis of avoidant PD, another had a diagnosis of dependent PD and one had a diagnosis of obsessive-compulsive PD, and the rest of the patients had no comorbid PD diagnosis. A statistically significant and high increase could be seen in the patients’ level of functionality in the mean general scores and in terms of the highest level achieved in the last year (Table 4). When we examine the duration of continuance to psychotherapy, eight people continued for four years, one person continued for five years, another person for seven years, two people for eight

Termination phase %


17.6 35.3 47.1

5 0 12

17.6 5.9 76.5

0 0 17

23.5 29.4 47.1

3 0 14

17.6 82.4

0 17

47.1 35.3 17.6

1 0 16

11.8 17.6 70.6

0 0 17

29.4 70.6

1 16

5.9 94.1

0 17

76.5 23.5

4 13

% 29.4 0 70.6 0 0 100 17.6 0 82.4 0 100 5.9 0 94.1 0 0 100 5.9 94.1 0 100 23.5 76.5

years, one person for nine years and four people continued for 10 years. In our study, 12 people terminated the psychotherapy procedure as planned by arranging a time for termination together with the psychotherapist, six people terminated as planned but primarily with their own request and one person terminated without any plans on telephone as a drop out (Table 3, Patient no: 16/BS). It is seen that those who have a diagnosis of borderline, narcissistic and histrionic PD stay in therapy for a longer duration and have the need for psychotherapy for a longer time. It was evident that those who continued psychotherapy for more than five years had statistically significantly more suicidal ideation (z = −2.04, p < .05), substance use (z = −1.96, p < .05) and self-mutilative behaviors (z = −2.69, p < .01) in the beginning than others (compared with the Mann–Whitney U).

MMPI scores Because the sample size is below 30, the relationships between the mean T values of MMPI subtests in the beginning and after the termination phases were examined with the Wilcoxon Signed Rank test. The results can be seen in Table 5. According to those results, in the MMPI subtests administered at the beginning F, 2 (D), 4 (Pd), 8 (Sc) had increased the most, followed by 3 (Hy) and 6 (Pa). In the termination phase, in the MMPI mean group profile, all of the subtests other than 4 (Pd) are within the T score range of 40–60 that is considered as the normal range; they form a code type. The 4 (Pd) sub-test is closer to the upper border of the mild level at the 63 T value. In the assessment with the Wilcoxon test, statistically significant regression to the normal values was observed in F, K, 1(Hs), 2(D), 3(Hy), 4(Pd), 6(Pa) and 8(Sc) in the MMPI subtests, compared to the beginning test scores.

380 Table 3 Axes I and II diagnoses, according to the DSM-III-R criteria and level of functionality in the beginning and after the termination phases, the duration of psychotherapy, age at onset of treatment, gender, patients’ initials and the style of the termination of psychotherapy. Patients N: 17


Beginning phase


GAFb general/highest

Borderline PD Narcissistic PD Borderline PD


Paranoid PD Avoidant PD Passive-aggressive PD Histrionic PD Narcissistic PD Histrionic PD Obsessive-comp.


Borderline PD Schizoid PD Histrionic PD


Borderline PD Avoidant PD Schizoid PD Avoidant PD Dependent PD Schizoid PD Histrionic PD Histrionic PD Narcissistic PD Passive-aggressive PD


Borderline Avoidant PD Paranoid PD Paranoid PD Narcissistic PD Borderline PD Narcissistic PD Obsessive-comp. PD Borderline PD Paranoid PD Narcissistic PD Borderline PD Narcissistic PD


2 AÖ


Major depression Vaginismus Major depression

3 YE


Major depression

4 UC


5 ET


6 AG


Major depression Panic disorder Obsessive compulsive dis. Panic dis. with agoraphobia Major depression

7 SA


Bulimia nervosa

8 AS


Major depression

9 MC¸


Social phobia

10 YS


Major depression

11 TA


Major depression

12 GB


13 EY


14 AA


Major depression Generalized anxiety dis. Major depression Social phobia Psychotic disorder NOS Alcohol dependence Major depression

15 SG


16 BS


Major depression Obsessive compulsive disorder Major depression

17 HS


Major depression


FM: female; M: male. GAF: global assessment of functioning.

Termination phase

Diagnose DSM-III-R Axis I


GAFb general/highest

Received no diagnosis Nine years (with its own request, planned) Eight years (planned, together with Received no diagnosis the therapist) Four years (planned, together with Received no diagnosis the therapist)

Received no diagnosis Received no diagnosis Received no diagnosis


Five years (planned, together with the therapist) Four years (planned, together with the therapist)

Received no diagnosis

Received no diagnosis Received no diagnosis


Eight years (planned, together with the therapist) Four years (with its own request, planned) Four years (with its own request, planned) Four years (with its own request, planned)

Received no diagnosis


Received no diagnosis

Received no diagnosis Received no diagnosis Avoidant PD

Received no diagnosis

Schizoid PD


Four years (with its own request, planned) Four years (with its own request, planned) Four years (planned, together with the therapist)

Received no diagnosis

Received no diagnosis Received no diagnosis Received no diagnosis



10 years (planned, together with the therapist)


Received no diagnosis



10 years (planned, together with the therapist) 10 years (planned, together with the therapist)

Received no diagnosis



Seven years (drop out on telephone)

Diagnostic assessment could not be carried out

Received no diagnosis Obsessivecompulsive PD 56/59


10 years (planned, together with the therapist)

Received no diagnosis

Received no diagnosis



55/58 59/60



45/49 55/60 55/59


Received no diagnosis

Received no diagnosis

Received no diagnosis Received no diagnosis

Received no diagnosis

70/75 69/71


70/71 65/68

65/71 65/68


N. Eren et al. / The Arts in Psychotherapy 41 (2014) 375–385

Diagnose DSM-III-R Axis I 1 AD


Duration of psychotherapy/style of the termination

N. Eren et al. / The Arts in Psychotherapy 41 (2014) 375–385


Table 4 Mean values and standard deviations of Global Assessment of Functioning Scale (GAF) and the highest functionality scores received in the last year, Wilcoxon test results of the differences between functionality scores in beginning and termination phases. GAF n = 17

Ort ± SS



Beginning general evaluation Termination general evaluation

50.06 ± 7.28 66.59 ± 4.93



Beginning highest level reached Termination highest level reached

54.24 ± 7.00




70.12 ± 4.77

p < .001.

Table 5 MMPI subtests mean scores, standard deviations and exploration of differences between the beginning and termination phases of psychotherapy with Wilcoxon test. MMPI subtests n: 16

Ort ± SS

(L) Beginning Termination

41.20 ± 7.81 45.56 ± 12.28


(F) Beginning Termination

67.00 ± 17.24 56.11 ± 17.23



(K) Beginning Termination

42.60 ± 8.82 50.33 ± 9.124



1. Hypochondriasis (Hs) Beginning Termination

63.60 ± 13.03 54.44 ± 11.56



2. Depression (D) Beginning Termination

73.10 ± 12.45 62.44 ± 13.27



3. Hysteria (Hy) Beginning Termination

65.80 ± 14.77 61.56 ± 11.59







Case 1/AD

4. Psychopathic deviate (Pd) 70.50 ± 8.64 Beginning Termination 63.89 ± 10.08 5. Masculinity/femininity (Mf) Beginning 49.80 ± 8.57 Termination 52.00 ± 10.35

.259 *



65.60 ± 10.08 56.00 ± 12.10



7. Psychasthenia (Pt) Beginning Termination

63.30 ± 11.87 59.44 ± 14.22



8. Schizophrenia (Sc) Beginning Termination

67.80 ± 15.13 59.11 ± 14.57



9. Hypomania (Ma) Beginning Termination

55.80 ± 11.13 50.89 ± 14.26



10. Social introversion (Si) Beginning Termination

61.40 ± 12.55 59.22 ± 12.48




In Fig. 1, there is an artwork which was created in the sixth month of psychotherapy. At the beginning of the session, AD started by stating that she felt very bad when she was with a man whom she met that week and found very attractive. Upon the therapist’s suggestion she worked with that feeling through painting. In the artwork, AD shared her idea that she went out of the shield where she feels safe when she was with someone attractive whom she wanted to get closer to. Then she felt almost as if she lost boundaries and her organs fell to pieces. It was possible to work through in depth “patients’ fears of losing integrity and disintegration outside the narcissistic shield (bell glass)”. With the artwork she created in this session we could address patient’s perception of close relationships. Case 6/AG

6. Paranoia (Pa) Beginning Termination


Fig. 1. A drawing depicting the fears of losing unity and disin.

The artwork in Fig. 2 represents the transferential relationship with the therapist in the second year of psychotherapy. It reflects the patients’ efforts for incorporating the therapist in herself and identifying with the functions of the therapist. While talking about this artwork, patient turned toward the therapist and said: “I look at you and I want to be like you”. Working on this artwork where the transference relationship became visible, provided a safe ground for investigating AG’s relationship with the therapist in proceeding sessions.

p < .05. p < .01.

Case examples of psychotherapy with artwork Below, there are examples of artwork from art therapy sessions of different time periods with different subjects for the reader to comprehend how the study proceeded. The examples represent different situations in psychotherapy. Diagnoses and functionality levels of the selected cases can be seen in Table 3.

Fig. 2. Working transference with drawings the eye watching the therapist and staring to internalize himher (Patient no. 6).


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Fig. 3. A drawing depicting split object representations of angel and devil and their effects on suicidal ideations (Patient no. 13).

Case 2/AÖ In Fig. 3, we see the artwork created by the patient AÖ in the second month of psychotherapy, who was initially silent and had a negativist attitude in sessions. At the beginning of the session AÖ mentioned two conflicting forces inside her that she cannot talk to anyone about, which continuously push her toward extreme behaviors. Therapist asked her if she could express those two forces and what they do to her in artwork. Accepting this suggestion, AÖ started working and drew a woman lying on a bench, who had killed herself with a gun in the center of drawing. Right next to the woman’s head was the devil who told her to commit suicide and near her feet was an angel who could not protect her. There was blood everywhere. There was a bird which spread its wings and flew over the bench. AÖ told the therapist that in this drawing, the angel was inadequate, the devil which symbolizes malignity took over her and that after her death she was free as a bird. When the elements in this drawing was worked through with the therapist in depth, the insufficiency of the internalized good object (her mother had a diagnosis of schizophrenia), the fears of bad object presentations, their links to her anger and how it dragged her to suicidal ideas were discussed. It was also possible to define loneliness with the bird image, her need to be freed from this conflict and the need for someone to protect her. After this work, patient’s participation in the sessions increased. Working with art established “a safe connection” between the therapist and the patient which can be remembered later. Case 17/HS The theme brought by the patient, who had a history of sexual abuse and neglect in her childhood to the session at the second year of psychotherapy was as follows: “I am inside a vortex, and this pulls me inside like a well, almost inside a grave”. While the patient was working on it with painting, therapist joined in and it became a collaborative work (Fig. 4). The therapist drew supported stairs leading up to the vortex which the patient drew, the patient strengthened those stairs with a black pastel crayon and this way a way out of this vortex was constituted. This work provided a metaphor for the patient about how to use the therapy. Later, in one of the verbal therapy sessions AG explained the positive effect of the work that was carried out one year ago by saying the following: “. . .last year I drew myself in a deep well and you added the stairs, I thickened the stairs and then my fear subsided. . .” In the progressive stages of psychotherapy, patients used the images/drawings

Fig. 4. Patient and therapist drawing together.

the way a child remembers the positive memories he/she experienced with his/her mother and uses them to endure the difficulties and disappointments that are faced later. Discussion When we investigate the results of long-term psychotherapy on patients at the termination phase, the regression in education and working domains had stopped; the level of education had increased, and the frequency of working and occupational progress and functionality had increased at a significant level. Compared to the beginning stage, self-mutilation, suicidal attempts, self-harm behaviors, hostility and impulse control issues had decreased significantly at the termination phase of psychotherapy. Most of the clinicians working with patients with PD agree that the increase in a patient’s level of functionality and amelioration of symptoms are the criteria for recovery, and results indicating partial or full recovery were reported in the literature, which are similar to the results in our study (Callaghan, Summers, & Weidman, 2003; Clarkin et al., 2005; Eren et al., 2000; Fonagy et al., 2005; Kraus & Reynolds, 2001; Stevenson & Meares, 1992; Stone, 1993; Zanarini, Frankenburg, Hennen, & Silk, 2003). The second most important finding of our study is the significant decrease in the frequency of Axis I and Axis II of diagnoses in the patients. The patients receiving psychotherapy for longer than five years were diagnosed with a cluster B personality disorder, most of them consisting of borderline PD, and none of those diagnosed as borderline PD at the beginning had met the criteria for borderline PD at the termination phase. Among all of the patients, only 17.6% (three patients) continued to have an Axis II diagnosis. Except for one patient, the patients did not receive any Axis I diagnosis. In the literature, it is reported that recovery in PD is not similar among different sub-types of cluster C; patients with several forms of anxiety achieve recovery faster than borderline PD

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patients, and borderline PD patients recover faster than schizotypal PD patients. Short-term psychotherapy is effective with cluster C PD, whereas a longer duration is required for severe PD. A good prognosis is not expected in antisocial PD; however, if there is comorbid depression, attachment and a positive therapeutic relationship could develop and contribute to recovery (Bond & Perry, 2004; Perry et al., 1999). In our study, a high level of depression was observed in the beginning; however, the depressive symptoms had ameliorated at the termination phase. The patients with borderline PD needed a longer duration of psychotherapy, and the positive therapeutic relationship achieved through artwork had a role in this progress and decreased the dropout rates. A fairly positive change has been observed in the patient MMPI profiles. In the beginning, the mean group profiles on the MMPI subtests displayed a graph parallel to the code type for BPD that is reported in the literature (Gustin et al., 1983; Hurt, Clarkin, Frances, Abrams, & Hunt, 1985). Those data are in line with the finding that 41% of the patients met the criteria for BPD in the DSM-III-R, Axis II diagnostic assessment. The other patients’ personality organizations are also at the borderline level. Various studies can be found on the MMPI profiles of borderline patients (Abromowitz, Carroll, & Schaffer, 1984; Evans, Ruff, Braff, & Ainsworth, 1984; Graham, 1987; Gustin et al., 1983; Hurt et al., 1985; Lloyd, Overall, & Click, 1983; Resnick et al., 1983). According to those studies, the highest scores are seen in the subtests of schizophrenia Sc(8), psychopathy Pp(4) and depression D(2), and the profile indicates approximately the 824-code type. The patient group with borderline features acquires significantly higher scores on the F, 4, 6, 8 and, sometimes the 2 subtests. Gartner, Stephen, and Gartner (1989) reports that usually 8, 4 and 2 subtests are followed by the sixth and seventh subtests, and the majority of the subtests are over 70 T points in the literature search. Abromowitz et al. (1984) found the mean profile as 8, 2, 7 for the patient group diagnosed with the (DIB). Resnick et al. (1983) reported an increase in the 4, 2, 8, 7 and 6 subtests. The consistency between those studies is interpreted as a validity of the 824-code type borderline personality diagnosis. There are studies showing that the MMPI validity scales are sensitive in a BPD diagnosis. In this patient group, among the validity subtests, an increase is seen in the F sub-test as well. Low scores are achieved (<50) in the K and L subtests, and thus those validity scales typically form a sharp reverse V figure. In the MMPI data in our study, significant decreases are observed in the termination phase of psychotherapy, in a particularly high level on the F, 1 (Hs), 2 (D), 3 (Hy), and 8 (Sc) subtests and in the K, 4 (Pd) and 6 (Pa) subtests. Those results indicate that the patients’ physical, somatic complaints (Hs), hopelessness, anhedonia, feelings of worthlessness and emptiness (D), unusual ideation processes, perceptual peculiarities and the ability to evaluate reality (Sc), difficulties in interpersonal relations, impulse and anger control issues (Pp), intense need for acceptance and love and conversive complaints (Hy), and level of suspiciousness and feelings of lack of safety (Pa) regressed to normal levels as a result of psychotherapy. Regarding the decrease in F, which is among the validity subtests, pathological personality features encompassing a wide range of maladaptiveness, such as not being open to cooperation and being socially unacceptable decreased. The increase of K to the normal range of defensiveness showed that the defense mechanisms had strengthened. Those results are encouraging because they indicate that longterm psychodynamic art psychotherapy could be a beneficial tool in the treatment of patients with severe PD. We hypothesize that working with art has contributed to the attachment of those patients to psychotherapy in the long term. In numerous studies involving psychotherapy results in the treatment of PD, it was found that a significant change in personality structure is only possible through long-term psychodynamic psychotherapy lasting five to


seven years. In particular, patients in cluster A and B, excluding those with antisocial personality disorder, do not show any significant change in the early stages of psychotherapy, specifically until the end of the second year. Only the patients who remain in psychotherapy for a longer time can benefit from recovery (Gabbard, 2001; Gunderson & Links, 2008; Meares et al., 1999; Waldinger & Gunderson, 1987). Bond and Perry (2004) reported recovery in the defense styles of patients with PD with long-term psychodynamic psychotherapy. The findings indicate that cluster C PD show faster recovery than cluster A and B PD and that patients with antisocial personality disorder could be treated with intense therapy where multiple techniques are involved and the environment is arranged therapeutically (Fonagy et al., 2005; Kraus & Reynolds, 2001). Because only a limited number of patients with antisocial PD apply to our clinic and those who do apply drop out in the first assessment phase or during the first year of treatment, no patients with a diagnosis of antisocial PD were included in our study. For patients with severe PD, establishment of cooperation for treatment and ensuring that they stay in psychotherapy for a long time period are essential for recovery (Callaghan et al., 2003; Gabbard, 2001). Short-term therapy with less severe PD could provide a significant degree of relief for comorbid symptoms (Propst, Paris, & Rosberger, 1994). In view of the deep-seated nature of personality pathology, most clinicians recommend long-term therapy as the treatment of choice. There are few research studies that evaluate the treatment results and efficacy of long-term psychotherapy for PD (Paris, 1998). This situation is a paradox for those with severe PD who experience difficulties with establishing long term, stable and significant relationships. Among the greatest difficulties in psychotherapy with these patients is negative transference, which develops under the effect of primitive defenses and results in severe acting-out reactions, with the therapist showing negative counter-transference reactions such as losing control, not being able to protect the frame of therapy, despair and anger (Gunderson & Links, 2008; Kernberg, 1984; Rossberg, Karterud, Pedersen, & Friis, 2007). It is a common hypothesis that those difficulties are important factors that affect drop out from psychotherapy (Meares et al., 1999; Smith, Koenigsberg, Yeomans, Clarkin, & Selzer, 1995; Stevenson & Meares, 1992). Art/drawing work was used to contain and transform the primitive representations and intense transferences projected to the therapy/therapist to a therapeutic work in the psychotherapy process of 17 patients. The artwork took place in every session during the first two years and less frequently in the following years as the verbal communication progressed. Through the expression achieved by drawing and painting, patients made progress in better understanding themselves and integrating their contrasting self and object representations. Art has rendered the development of a positive transference easier and allowed the patients to collect visual imagery that could be used when facing later disappointments; the imagery is kept emotionally alive and not forgotten. Patients frequently recalled the work of drawing/painting first while talking about the prior phases of psychotherapy. Those memories function as a bridge that promotes the continuity between the present and the past and are very beneficial in preventing the patients from dropping out of therapy by completely devaluing the therapist. Many studies have reported that art is very useful for developing creativity in people with severe mental problems (Eren et al., 2000; Jadi & Trixler, 1980; Lamont et al., 2009; McMurray & Mirman, 2001; Wadeson, 1980). Psychodynamic art psychotherapy was effective in enabling the 16 patients involved in our study to remain in psychotherapy without dropping out. The patient who dropped out in the seventh year by phoning that he would not continue therapy had an increase in functionality scores, which pointed to a partial recovery (Table 3, Patient no: 16/BS); however, this patient dropped out because of


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transference problems. Because the last evaluation could not be carried out, the data regarding this patient’s final condition could not be obtained. Conclusions We suggest that patients who manage to stay in psychotherapy fours or more show a significant decrease in their symptoms, an improvement in functionality and an increase in work and education success. Their high scores in F, Hd, D, Hy, Pp, Sc and Ma on the MMPI subtests regressed to normal levels, and the patients were able to develop more realistic relationships with the therapist. We suggest that art/drawing work in psychotherapy allowed working through by providing a good container and reduced the number of dropouts. Limitations The small number of patients in the study group and the lack of a control group with similar patients limit the generalizability of our results. In addition, the fact that there is no formal art psychotherapy education and supervision in Turkey is also a possible limitation regarding the use of art psychotherapy techniques. Acknowledgments We wish to thank the patients who participated for sharing their information and paintings with us. References Abbass, A., Town, J., & Driessen, E. (2011). The efficacy of short-term psychodynamic psychotherapy for depressive disorders with comorbid personality disorder. Psychiatry, 74(1), 58–71. Abromowitz, S. L., Carroll, J., & Schaffer, C. B. (1984). Borderline personality disorder and the MMPI. Journal of Clinical Psychology, 40, 410–413. American Psychiatric Association (APA). (1987). Diagnostic and statistical manual of mental disorders (DSM-III-R) (3rd ed. rev.). Washington, DC: American Psychiatric Association. Bateman, A. W., & Tyrer, P. (2004). Psychological treatment for personality disorders. Advences in Psychiatric Treatment, 10, 378–388. Bick, E. (1968). The experience of the skin in early object-relations. International Journal of Psychoanalysis, 49(2), 484–490. Bion, W. R. (1961). Experiences in groups. London, UK: Tavistock. Bond, M., & Perry, J. C. (2004). Long-term changes in defense styles with psychodynamic psychotherapy for depressive, anxiety, and personality disorders. American Journal of Psychiatry, 161(9), 1665–1671. Callaghan, G. M., Summers, C. J., & Weidman, M. (2003). The treatment of histrionic and narcissistic personality disorder behaviors: A single-subject demonstration of clinical improvement using functional analytic psychotherapy. Journal of Contemporary Psychotherapy, 33, 321–339. Choi-Kain, L. W., Zanarini, M. C., Frankenburg, F. R., Fitzmaurice, G. M., & Reich, D. B. (2010). A longitudinal study of the 10-year course of interpersonal features in borderline personality disorder. Journal of Personality Assessment, 24(3), 365–376. Clarkin, J. F., Levy, K. N., & Schiavi, J. M. (2005). Transference focused psychotherapy: Development of a psychodynamic treatment for severe personality disorders. Clinical Neuroscience Research, 4, 379–386. Eren, N., Özdemir, Ö., Ö˘günc¸, N. E., & Saydam, M. B. (2000). Evaluation of the dynamic oriented art psychotherapy group process in borderline patients [Borderline hastalarla yapılan dinamik yönelimli sanat psikoterapi grubunda sürecin de˘gerlendirilmesi]. Journal of Psychiatry, Psychology, Psychopharmacology, 8(4), 285–294. Evans, R. W., Ruff, R. M., Braff, D. C., & Ainsworth, T. L. (1984). MMPI characteristics of borderline personality inpatients. Journal of Nervous and Mental Disease, 172, 742–748. Fonagy, P., Roth, A., & Higgitt, A. (2005). The outcome of psychodynamic psychotherapy for psychological disorders. Clinical Neuroscience Research, 4, 367–377. Gabbard, G. O. (2001). Psychodynamic psychotherapy of borderline personality disorders. Bulletin of the Menninger Clinic, 65, 41–57. Gartner, J., Stephen, W. H., & Gartner, A. (1989). Psychological test signs of borderline personality disorder: A review of the emprical literature. Journal of Personality Assessment, 53(3), 423–441. Graham, J. R. (1987). The MMPI: A practical guide. New York, NY: Oxford University Press.

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