Art Therapy and Bipolar Disorder

Running Head: Psychoeducational Group Art Therapy

Psychoeducational Group Art Therapy for Bipolar

Disorder

Christy Pardee

Wayne State University

12/1/14

Psychoeducational Group Art Therapy

Introduction

According to the American Art Therapy Association

(AATA) (2014) art therapy is defined as:

a mental health profession in which clients, facilitated by the art therapist, use art media, the creative process, and the resulting art work to explorefeeling, reconcile emotional conflicts, foster self awareness, manage behavior, develop social skills, improve reality orientation, reduce anxiety and increase self-esteem.

Dr. Kay Redfield Jamison, a psychiatry professor who

has bipolar disorder (also known as manic-depression)

provides strong evidence for a link between creativity and

bipolar illness (1993). Bipolar individuals may naturally

use creativity to understand and heal themselves through

art; however, this mysterious link between bipolar disorder

and creativity is not yet explained by psychiatrists

(Mondimore, 2014). Spaniol also suggests a link between art

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and mental illness, indicating that art can be used for

insight and emotional growth (2001).

Literature Review

Spaniol (2012) found that amongst those with severe

mental illness, those with bipolar disorder have a high rate

of recovery when appropriate treatment takes place. In this

population, art therapy can help manage difficult emotions

and offers a potential for growth. Art therapy provides a

focus on long term hope for prognosis.

Chandraiah etal, (2012) found evidence for the use of

short-term art therapy in a heterogeneous group of depressed

individuals, one who had bipolar depressive symptoms. All

the patients in the study had statistically improved

depression scores as a result of the art therapy group. The

patients learned from each other’s distress and experienced

appropriate feedback. Art provided distance from their

problems, and they achieved a sense of mastery by using art

materials. This last finding, the concept of mastery, would

be of great use to those struggling with bipolar symptoms

both in the manic and depressive range.

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Regarding scholarly research on art therapy and bipolar

disorder, studies often examine group art therapy with mixed

psychiatric diagnoses (Drapeau, Kronish, 2007). Drapeau put

together a group of persistently ill psychiatric patients

for art therapy. Bipolar patients were included, as were

other psychopathologies. This art therapy program showed a

positive outcome for all participants.

In contrast to the use of a heterogeneous group,

Miklowitz (2002) recommends a homogenous group environment

(one of only bipolar individuals) so that members can share

similar experiences and advice. Although medication is a

first step towards stabilization in bipolar disorder, group

psychotherapy has been found to be helpful as a necessary

adjunct especially within the first year. It can help

patients 1.) accept their diagnosis, 2.) gain information on

managing stress and triggers, and 3.) bring attention to

serious issues such as suicide prevention and trauma that

occurs as a result of having an episode (Miklowitz, 2002,

Mondimore, 2014).

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Both Miklowitz (2002) and Spaniol (2012) suggest a

psychoeducational theoretical approach for those with

bipolar. This provides an instructional atmosphere and

provides facts about the illness. Psychoeducational art

therapy can provide insight about warning signs of relapse,

traumas that occurred during episodes, and developing a

personal support system.

Population

Due to the inherent creative background of bipolar

individuals, the art therapy research by Spaniol (2012), and

research supporting the use of psychoeducational support

groups in this population (Miklowitz, 2002), it seems

natural that an art therapy group using psychoeducation

would be beneficial.

According to Rubin (2001) psychoeducational art therapy

emphasizes learning: the acquisition of new behaviors and

new skills. Rosal (2001) successfully used this method for a

depressed adult. Using art imagery, she devised an art

experience that visualized a plan for before, during and

after treatment. As well, mind state drawings were helpful

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and an increased sense of control was achieved in this

patient.

It is the purpose of this paper to propose an art

therapy group program for those with a primary diagnosis of

bipolar disorder. The synthesis of research on affective

disorders, psychoeducation, and art therapy provides

evidence for such a program.

Three Treatment Goals:

The first week , the goal will be for group

participants to learn about what bipolar disorder

is and to better accept that they have this

condition.

The second week, the goal will be to increase

self-management skills for living with bipolar.

The third week, will approach more serious, deeper

issues that persons with bipolar often face as a

result of their episodes.

This 2 hour group will be offered as part of an

intensive outpatient day treatment program taking place 4

days a week (Monday through Thursday) for 3 weeks, for a

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total of 12 sessions. There will be 45 minutes of art making

and 45 minutes of discussion.

Referrals for Program

Participants will be recruited through a psychiatric

hospital that offers a day treatment program. A

psychiatrist’s Diagnostic and Statistical Manual (DSM)

diagnosis of bipolar I or bipolar II is required. Acutely

psychotic/manic individuals are excluded; as well, actively

suicidal individuals are excluded. Regarding cognitive

function, the participant should have achieved approximately

a high school level of education due to the reading

components of the group. It is expected that participants

will make a verbal agreement to engage in medication

therapy, including necessary blood tests. (Art therapy is

not a replacement for psychiatric care). This program is

recommended for those with a desire to use visual creativity

as a way to both understand and improve their management of

this condition. Also the group can help improve

socialization skills as discussion of art takes place. A

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Registered Art Therapist (ATR) and another professional

trained in mood disorders will co-facilitate the group.

Assessment

Prior to the 1st group meeting each participant will

have an appointment with the ATR to do a psychosocial intake

(Appendix 1) and an art-based assessment of stress level.

According to Mondimore (2014), life stress can be a major

trigger for bipolar episodes. For this reason it is

appropriate to use the Draw a Person in the Rain art based

assessment pre and post treatment (Appendix 2)

(Vernis, Lichtenberg, Henrich, 1974).

This assessment diagnoses the client’s current level of

life stress. The amount of rain drawn is thought to indicate

the stress on the person, and protective measures such as an

umbrella and coat indicate how the client copes with the

stress. It is predicated that clients will increase their

protection from the rain/stress as a result of the art

therapy group. This will help with bipolar self-management

and protect from future episodes.

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Session 1 Goal 1: Learn about what bipolar disorder is

and better accept that they have this condition.

Objective: Clients introduce themselves to the group.

Intervention: (Adapted from Spaniol, 2012) As an

introduction to the group, client depicts how they feel

today, using a weather condition. Instruct clients to use

color, line and/or form.

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Each client will be provided with an 11x17 white piece

of computer paper to draw on. They are free to use any 2

dimensional drawing media in the art room. This includes

pastel, marker, crayon, pencil. If anyone finishes early,

they may do a free drawing.

After a 45 minute interval (or if everyone states they

are finished), stop working. The clients state their first

name for the group and discuss what they have drawn. The

rest of the group only witnesses the art and description for

the first week, no cross-talk . It is explained to the group

that this is a safe, confidential space and that everything

that happens here, stays here for the duration of the

program.

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Session 2 Goal: Learn about what bipolar disorder is


Objective: Clients will learn about the description of

bipolar disorder.

Intervention: Clients will receive the Mood Information

Sheet (Appendix 3) describing features, experiences and

symptoms of bipolar disorder. Clients are asked to quietly

reflect on the information sheet and then depict by drawing

or painting, their understanding of bipolar disorder.

Clients this week can choose any size drawing paper, or

an appropriate painting surface that is available in the art

room. Watercolor, acrylic and tempera are available. Pencil,

cray-pas, pastel and marker and crayon are also available.


are finished), stop working. Clients discuss what they have

drawn. The rest of the group only witnesses the art and

description for the first week, no cross-talk.

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Objective: Client will express their unique personal

experience with bipolar disorder.

Experiential: Based on what was learned in Session 2,

there are two choices today. Clients can depict their “Aha!”

moment, the time they knew themselves to have bipolar

disorder. Or they can depict why they doubt having the

condition.

Again they can use drawing or painting. They can choose

from available sizes of drawing paper or painting surfaces.

Watercolor, acrylic or tempera paint are available as are

pencils, markers, cray-pas, crayons and pastels.

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Objective: Clients will learn about the causes of

bipolar disorder

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Intervention: Using Bipolar Causes Information Sheet

(Appendix 4), clients will depict a narrative of their most

recent episode.

Clients will be provided with an 11 x 17 piece of

computer paper. They are asked to fold it into 4 equal

squares and number each square. At the top of each square,

write at least one word, creating the story of their most

recent episode, including a beginning middle and end. They

are then asked to illustrate the word/s written in each

square. Only graphic material are provided for this

intervention such as pencils, colored pencils, and pens.





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Session 5 Goal 2: Self-management of bipolar disorder

Objective: Client will identify stress triggers that

can induce an episode.

Intervention: Client will depict a situation that

triggers stress in their life (Spaniol, 2012).

Clients are encouraged to try paint today. The art room

has watercolor, acrylic and tempera. Canvas boards, and

watercolor paper are made available.


are finished), stop working. Client discusses what they have

painted. After each group member has had a chance to

describe their work, if there is time remaining, the group

is opened for discussion. Cross talk is encouraged. Because

this is the first time with open discussion, the following

group norms are presented on a large piece of poster board:

No verbal attacking of fellow group members.

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Try to keep your comments brief so everyone has time to

talk.

Try to keep comments to your own feelings or

experience, avoiding advice-giving.

We are not psychiatrists, so stay away from

recommending certain medications.


Objective: Clients will develop a strategy for dealing

with the symptoms of stress that may be triggers for the

bipolar condition.

Intervention: Clients will close their eyes and do some

deep breathing. Then, in their minds eye, visualize a

peaceful stress-reducing scene and draw a picture or paint

it (Spaniol, 2012).

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Clients have their choice of materials today. Paint and

drawing materials are made available. Different sizes of

paper or painting surfaces are available.



painted. If there is time remaining, the group is opened for

discussion. The poster board with group norms is made

visible.

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Objective: Clients will begin to develop ideas for a

social support network using the Social Support Information

Sheet (Appendix 5).

Intervention: Clients will draw a social support

diagram with themselves in it (Spaniol, 2012). This can be

current or hoped for in the future.

Clients will be provided with a larger size piece of

drawing paper. Media will be pencils, markers, colored

pencils, and pens. They are verbally encouraged to use up

the whole space.


are finished), stop working. Clients are encouraged to

discuss their diagram. If there is time remaining, the group

is opened for discussion. The poster board with group norms

is made visible.

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Objective: Client will identify a positive sense of

self (Spaniol, 2012)

Intervention: (Spaniol, 2012) Clients will depict the

proudest moment of their whole life, no matter how small.

Alternatively, clients will depict something they like about

themselves today.

Open studio, all 2 dimensional materials are open for

use and choice. If clients have a hard time choosing they

can ask for suggestions from the ATR.


are finished), stop working. The clients discuss their work.

If there is time remaining, the group is opened for

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visible.

Session 9 Goal 3: Explore deeper feelings related to

bipolar disorder.

Objective: The topic of suicide will be addressed. One

in 5 bipolar lives end in suicide (Spaniol, 2012). A suicide

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safety plan will be the focus of todays work using Suicide

Prevention Sheet (Appendix 6).

Intervention: Again, using a larger sheet of drawing

paper, depict using drawing media, what would you see, hear

and think to prevent suicide. How might you respond if

suicidal thoughts emerged? Think of objects such as a phone

to call a support person.


are finished), stop working. The clients discuss their work.

If there is time remaining, the group is opened for


visible.

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Session 10 Goal 3: Explore deeper feelings about

bipolar disorder.

Objective: Clients will explore trauma. Did a trauma

trigger a bipolar episode, or did bipolar disorder result in

a trauma after the fact? Was their hospital experience

traumatic?

Intervention. For the first time today clients will use

a 3 dimensional media. Crayola clay will be provided.

Clients will be advised to sculpt, model, or carve the clay

in a way to express any traumatic feelings or memories that

relate to their experience with bipolar disorder. Their

clay product can be abstract or representational.


are finished), stop working. Each client discusses their

clay work. If there is time remaining, the group is opened

for discussion. Today, and only today, the ATR and the other

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treatment professional will make themselves available after

group in the case that extra verbal processing is needed.

The poster board with group norms is made visible.


bipolar disorder.

Objective: Clients will be encouraged to bypass normal

psychological defenses and access their inner selves (Hanes,

1997).

Intervention: Clients are provided a 12x 18 piece of

white paper with a 2B pencil crayons, cray-pas pastels and

colored pencils. They will then be instructed to think about

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the circus and its performers and sideshows, then choose a

performer that appeals to them or comes to mind. Try to draw

that performer exhibiting bipolar symptoms. If they cannot

depict this, instead draw the figure doing an action of some

sort. Try to draw the whole figure and avoid stick figures

(adapted from Hanes, 1997).


are finished), stop working. The clients then discuss their

circus character. If there is time remaining, the group is

opened for discussion. The poster board with group norms is

made visible.

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bipolar disorder.

Objective: In this closing session, clients will focus

on their sense of self.

Intervention: Clients will have a brief meditation on

their inner strengths. They are then instructed to depict a

visual self-symbol using a cardboard white mask (adapted

from Spaniol, 2012). Clients are each provided with a mask,

and the studio is open. Also, Elmer’s glue, glitter and

feathers are provided for the first time.


are finished), stop working. Each client discusses their

self symbol and is asked to talk about what they have

learned in the 3 week group. If time allows there will be an

open discussion. The poster board with group norms is made

visible.

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Appendix 1

BioPsychoSocial Intake:

1. Client name and phone number

2. Name and number of emergency contact

3. Date of birth

4. Age

5. Referral Source

6. Description of client

7. Major problems and duration

8. Previous treatment

9. Medical problems

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10. Medications currently taking

11. DSM Psychiatric diagnoses

12. Any substance abuse history

13. Any current life stress

Appendix 2

(use pre and post group therapy)

Draw a Person in the Rain Art Therapy Assessment Procedure:

Client is given a #2 pencil and an 8x11 piece of computer

paper. The client is then instructed to draw a person in the

rain. This should take about 20 minutes.

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The ATR will interpret the image using Vernis, Lichtenberg,

Henrich (1974).

Appendix 3

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Mood Information Sheet (this is a short list, see these

books or your psychiatrist for more information)

from: Miklowitz, D. J. (2002) The bipolar disorder survival

guide: what you and your family need to know. New York: The

Guilford Press

What bipolar disorder looks like:

highs and lows, a roller coaster, changes in energy,

changes in thinking and perception, suicidal thoughts,

sleep problems, impulsivity and self-destruction, all

over the map, like a see-saw

from: Copeland, M. E. (2001) (2nd Editions) The depression

workbook: A guide for living with depression and manic

depression. Oakland, CA: New Harbinger Productions

Experiencing Depression : hopeless, useless, apathetic,

desire only for sleep, sad, anxious, cry easily, might

as well be dead, lonely, no motivation, inability to

sleep, angry, ugly, in hell, pain that can’t be fixed,

disorganized, obsessed with past mistakes.

Experiencing Mania or Hypomania: energetic, speedy,

talking very fast, very happy, “know it all,” need to

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do something, compulsive buying, pressured speech,

euphoric, exalted, brilliant, grandiose,

hallucinations, paranoia, cruel, arrogant, inability to

concentrate, dangerous sexual behavior that is

destructive

Appendix 4

Bipolar Causes Information Sheet (Milkowitz, 2002)

1.) Initial starting episodes are often linked to

having a genetic family history with the bipolar (also

called manic-depression). Keep in mind that in the past

bipolar was not described as it was now. There may have

been an “extremely moody” or “nervous” relative, a

psychotic relative, or even a relative that may have

been misdiagnosed as schizophrenic, which was common.

2.) New episodes, following the first, often develop

from triggering events such as: environmental stress,

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sleep disruptions, alcohol or substance abuse or drug

nonconcordance.

Stress agents can be positive or negative

like a job change, change in living

situation, money problems, family conflict,

changes in a romantic relationship.

Appendix 5

Social Support Information Sheet (Copeland, 2001)

For your support team, choose:

people you trust and love

people you can count on

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people who empathize

people who affirm your strengths

people who you can play games with or be creative with

people who are open-minded

people who accept your ups and downs without judging

people who give and take in a mutual manner

someone you can talk to in person, on the phone, or

through correspondence

someone to spend time with

a safety monitor during emergencies

Appendix 6

Suicide Prevention Tools (Copeland, 2001)

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Do relaxation techniques

Contact your support system

If you have extra prescription pills “saved up” flush

them or give them to a support person.

Get rid of firearms

Hand over car keys to a support member

Express you feelings

Get support, don’t isolate

Stay on your medication as prescribed

Talk, and talk more with a counselor

Write

Pray

Go to a support group

Ask for help

Call your psychiatrist

Go to a emergency room or call 911

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References

American Art Therapy Association (2014,11,30) Retrieved

from:

http://www.arttherapy.org/aata-

aboutus.html#whatisarttherapy

Chandraiah, S., Anand, A. S., Avent, L. C. (2012) Efficacy

of group art therapy on

depressive symptoms in adult heterogeneous psychiatric

patients. Art Therapy: Journal of the American Art Therapy

Association. 29(2)80-86

Copeland, M. E. (2001) (2nd Edition) The depression

workbook: A guide for

living with depression and manic depression. Oakland,

CA: New Harbinger Productions

Drapeau, M. C., Kronish, N. (2007) Creative art therapy

groups: a treatment modality

for psychiatric outpatients. Art Therapy: Journal of the

American Art Therapy Association. 24(2) 76-81

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http://www.arttherapy.org/aata-aboutus.html#whatisarttherapy

http://www.arttherapy.org/aata-aboutus.html#whatisarttherapy


Hanes, M. J. (1997) Utilizing the circus phenomenon as a

drawing theme in

art therapy. The Arts in Psychotherapy 24(4) 375-384

Jamison, K. R. (1993) Touched with fire: manic-depressive

illness and the artistic

temperament. New York: Free Press Paperbacks, Simon and

Shuster.

Miklowitz, D. J. (2002) The bipolar disorder survival guide:

what you and your

family need to know. New York: The Guilford Press

Mondimore, F. M. (2014) (3rd Edition) Bipolar disorder a

guide for patients and

families. Baltimore: Johns Hopkins University Press

Rosal, M. L. (2001) Cognitive-behavioral art therapy. In

Rubin J., A. Approaches to Art

Therapy Theory and Technique. (2nd Edition) 210-225 New

York: Routledge

Rubin, J., A. (2001) (2nd Edition) Approaches to Art Therapy

Theory and Technique

New York: Routledge

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Spaniol, S. (2001) Art and mental illness: where is the

link? The Arts in

Psychotherapy. 28: 221-231

Spaniol, S. (2012) Art therapy with adults with severe

mental illnesses. In Malchiodi,

C., A. Handbook of Art Therapy (2nd Edition) 288-300 New

York: Giulford Press

Vernis, J. S., Lichtenberg, E. F., Henrich, L. (1974) The

draw a person in the rain

technique: its relationship to diagnostic category and

personality indicators. Journal of Clinical Psychology. 30(3)

407-414

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Client Satisfaction Survey

1.) Were the group leaders helpful or unhelpful? Were

they kind and empathetic? Why or why not?

2.) Did you learn new information about bipolar disorder

from the art experiences? If so what did you learn?

3.) Will your behavior and self-management change as a

result of the program?

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4.) Did you enjoy the visual creative aspect of the

program? Was it a pleasure to do the art experiences?

5.) Did the art room studio sufficiently provide

supplies that you needed? What else do you think should

be supplied?

6.) Any other suggestions?

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Art Therapy and Bipolar Disorder

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