Group art therapy as adjunct therapy for the treatment of schizophrenic patients in day hospital

Introduction. The schizophrenics are frequently disinterested and resistant to standard care. Case report. We presented clinical observations of group art therapy of two schizophrenic patients during integrative therapy in Day Hospital. We modified the original “Synallactic collective image technique” (Vassiliou G, Vassiliou V.). The group is open, heterogeneous, meets once a week and discusses on exhibited drawings, drawn by free associations. The patients' drawings and group protocols showed clinical improvement by lowering depressive themes, more human figures and self-confidence. The obvious severity of markedly impairment on Clinical Global Impression (CGI) and Global Assessment of Functioning (GAF) scales on admission with minimal improvement at discharge was rated. Conclusion. Group art therapy enables visual expression of emotions, perceptions and cognitions, develops creative potentials and support within the group, thus facilitating the integrative therapeutic process of schizophrenics. It may be useful adjunctive therapy for schizoprenic patients.


Introduction
Schizophrenia is a severe, chronic condition affecting person's cognition, emotions, perception and complete behavior.It most commonly occurs in adolescence with prevalence rates reaching 1% of the total population 1 .Treatment and rehabilitation of schizophrenia patients have become a big socio-medical concern 2 .In spite of the advances in pharmacotherapeutic treatment, symptoms of schizophrenia accompanied by the reduction in the normal flow of communication could be frequently seen in those patients.Therefore, art therapy coupled with other creative therapies used as an adjunctive method in combination with drugs, might be helpful in obtaining an insight into the patients' inner world, without making them feel threatened 3 .Having been developed some 60 years ago, art therapy was focused on developing good communication skills through arts 4 .
After the acute treatment phase and hospitalization, or due to worsening of their condition during maintenance therapy, such patients are referred to day hospitals for further treatment, where, in addition to their pharmacotherapy, they attend various psychotherapeutic and sociotherapeutic sessions 5 .
Since the development of art therapy and its introduction into psychiatry clinical practice, the clinicians' attention has mostly been focused on the drawing's content as a diagnostic tool.Investigation of art therapy effectiveness in the schizophrenia treatment conducted over the recent decades, led to its inclusion into some national treatment guidelines for schizophrenia as a treatment option recommended for the management of all types of this disorder 6 .However, there is little or insufficient knowledge of the availability, organization and the way of conducting art therapy programs, not only when our community is concerned, but other national healthcare facilities as well 7 .
More than 20 years ago, the author of this paper from the Day Hospital of the Military Medical Academy's (MMA's) Psychiatry Clinic modified, to some extent, the technique called by its creators, George and Vasso Vassiliou, the "Synallactic collective image technique" 8 .The original method was based on the systematic understanding of group therapy processes, and was focused on only one drawing voted in the course of session by the members in a homogeny group 9 .But in our case, we modified the said technique in a way to adjust it to the heterogenic composition of the group, as well as to the integrative therapy, which is used in our Day Hospital 10 .Thus, an open, heterogenic group of patients meets once a week.During the group therapy process, a therapist and a co-therapist lead the group in a structured way: the drawings that the patients have made by free associations and brought to group therapy are exhibited, then voted, and discussed for the ninety minutes.On completion of the session, the therapists conduct a qualitative analysis of the drawing form and content, and the group therapy protocols as well using the experience of co-observers.
This paper is set of clinical observations and therapeutic possibilities of the art therapy through its application in the Day Hospital treatment of two schizophrenic patients, describing their general health condition and functioning at the time of their admission and discharge, two months later.
On both admission and discharge, an overall clinical assessment of the patients' condition and functioning was rated on a seven-point Clinical Global Impression Severity (CGI-S) Scale 11 , and the Global Assessment of Functioning (GAF) Scale 12 by an independent psychiatrist not involved in the group art therapy, whilst the patients' improvement at the time of their discharge was rated on the Clinical Global Improvement (CGI-I) Scale 11 .
The patients expressed their written consent for the participation in group therapy and the use of their drawings for such purposes.

Case report
Our first case was a 31-year-old female patient, graduated from the School of Arts, who was unemployed, of the average material status, single, lived with her mother who gave her considerable support during the treatment.For almost ten years, she was treated for paranoid schizophrenia associated with a considerable social withdrawal and other residual symptoms dominating her clinical picture over the last three years.However, there were no psychotic disorders observed in her family anamnesis.She was on the maintenance therapy with the long-acting depot preparation of classical antipsychotics, anxiolytics and antidepressants.As her condition accompanied by social isolation, distrust of people and mild paranoid delusions, the feeling of abandonment and depression worsened, she was referred to Day Hospital.Her admission GAF score was 51, while the CGI-S score was 5 (markedly ill).The theme of her first drawing (Figure 1), was a depressive one depicting flowers bending over the sides of a vase dominantly standing out against a pale and empty background.Prior to her discharge, she drew a dead nature motive similar to that drawn upon her admission (Figure 2), but this time, with the addition of blooming flowers standing straight up in a more colorful vase and background filled with new elements.However, the patient was fond of drawing, for it was her chosen career she couldn't ever pursue due to her illness.Her drawings were most often voted by the other patients during the group analysis sessions.That was practically the only activity through which she could demonstrate her genuine potentials and gain gratification.She became more open with the other members in the group, and her paranoid delusions were considerably minimally expressed.At discharge, her GAF score was 56, CGI-S was 5, while CGI-I was minimally improved.
The second case was a 27-year-old male patient, a second school graduate, a single young man living with his primary family, fled from the war-affected area, exposed to prolonged psychosocial stresses.He has a heterozygous twin brother and an elder one, both of whom are healthy.He felt secluded from his family, not being supportive enough.For the last nine years, he was treated for schizophrenia simplex with atypical antipsychotics and anxiolytics on the outpatient basis.However, as soon as his condition deteriorated along with the progression of negative symptoms accompanied by highly expressed social and emotional withdrawal and reduced efficacy, he was referred to the Day Hospital.
On his admission, the GAF score was 50, whilst the CGI score was 5 (markedly ill).During his first weeks, after admission, he kept drawing almost stereotypically the same house with evident signs of emptiness (Figure 3).At the group discussion sessions, his poor emotional experiences, difficulties with thinking and oral expression of poor meaningful contents, and very rare associations were evident.The other members in the group were very caring towards him, and recommended him, with a dose of humor, that he could add something else, at least a human figure, to the composition in his drawings.After several weeks he drew several houses.Then he continued to draw houses with windows wide open and those stick figures of men looking through it (Figure 4).Prior to his discharge, he drew a great many those figures out of the houses, thus, symbolically showing that he managed to overcome his feelings of social isolation (Figure 5).Each of his improvements in the content of his drawings was gratified by the members in group therapy, thus provoking a modest smile on his face.At the time of discharge, his GAF score was 55, CGI-S score was 5, and CGI-I was minimally improved.

Fig. 5 -A drawing of many figures of men showing that the patient overcame his feelings of social isolation
(prior to discharge).

Discussion
A personal feeling of alienation, helplessness, emotional deprivation, avoidable behavior and social isolation which are commonly seen in patients with schizophrenia 1 , were also reported in the presented cases.However, there are reports on clinical trials, the results of which showe that group art therapy did not help improve the global functioning of patients suffering from schizophrenia, and the outcome of their treatment as well 13 .The applied scale scores confirmed only a minimal improvement of the general health condition and functioning achieved in those two patients upon the completion of the Day Hospital integrative treatment.It could be explained by the fact that it was about markedly ill, chronic patients with persistent and expressed negative symptoms of schizophrenia, due to what an intensive recovery could not be expected during a 2-month treatment period.
Clinical assessment scales are a universal tool useful in the clinical practice, and required in clinical trials.However, mental health status of a patient is colorful and illustrated through drawings in a unique way and specific individual style.So, in the first case, a vase of flowers was a theme the patient kept drawing, but her improvement in the course of the treatment in the day hospital setting was evident.Her first drawing was expressively depressive and poor in color and forms symbolically reflecting her isolated, lonely and depressive dyad surrounded by emptiness.In spite of the same motive she had repeatedly drawn as the central focus of the whole composition, her drawings at the end of her treatment were filled with expressive, warm colors, more richer background, without previously emphasized sharp lines, clean borders and high contrast between the vase and its background.In addition to such progress in her artistic expression, she managed as well to intensify her interaction with the other group members in the course of this wellstructured therapy.The votes and clear gratification she got from the others helped her feel protected and accepted by the others, and encouraged her, at the same time, to build confidence in the group.
On the other side, poor performance and associations were evident in the second case.However, thanks to a warm support, and at the initiative of the other group members, he managed to enrich his stereotype expression and, to symbolically and clearly, demonstrate his reduced social withdrawal.It is an example of how the art of drawing is not considered to be either a dominant goal or a requirement for the art therapy, but an expressive tool that might help stimulate creative insights even in chronic patients.Thus, a relatively simple type of drawing made of lines has even the ability to make an impact on the patient to get an idea of what his/her own creative potentials are, and to facilitate communication within an intensive, interactive group.
What we could most clearly see from the drawings of presented patients was the reduction of both social and emotional withdrawal.The group played a significant role as a source of social support.It also encouraged the patient to regain and raise his/her self-esteem.Concurrently with the changes made to the composition of the drawings, the pa-tients started to attend the other therapeutic activities in our Day Hospital.Similar clinical observations on raising the self-esteem in schizophrenic patients attending the group art therapy were reported by other authors 14 .The randomized clinical trial confirmed a statistically significant reduction of negative symptoms of schizophrenia along with minor changes of other symptoms 15 , what was also observed in our cases.The same trial revealed as well a lower level of patients' attendance at the art group therapy, whilst our patients, along with the majority in the group, regularly participated in those therapy sessions.Another effects of integrative therapeutic process observed in schizophrenic patients, were a gradual shift of their focus from psychotic topics to an actual social context and the reality, and an approach and confrontation with the problems on the 'here and now' basis, what, thus, strengthened their sense of belonging to the group.
The basic limitations in assessing therapeutic possibilities of group art therapy presented here refers to the fact that it is only an adjunctive therapy that can be used as a part of the day hospital therapeutic program, what was confirmed by other authors 3,16 .However, we have noticed that once the group process was initiated at the art therapy sessions, it intensified the therapeutic process itself, and the change of topics in the group psychotherapy, in which smaller, homogeny groups of psychotic patients meet three times a week.The gap between schizophrenic and other patients visiting the Day Hospital for occupational, working and creative therapies has also been reduced.
The Day Hospital concept has more intensive therapeutic effects as compared with the out-patient treatment 16 .Such a complex integrative therapy imposed the need to set the framework and define the role of group art therapy in our Day Hospital Program.Group art therapy should comprise a clearly structured group process with limited objectives accommodated to the entire therapeutic process.It particularly refers to psychotic patients since the projective potentials of their drawings may additionally provoke the feeling of being threatened and the opposite reaction in them.Therefore, there is a need for a constant supervision of group therapists as members of the Day Hospital therapeutic team dealing with comprehensive diagnostic explorations of each patient, and monitoring of the whole pharmacotherapy, psychotherapy and sociotherapy.
In order to assess the effectiveness of group art therapy in schizophrenic patients, a clinical investigation of the differences in functioning and the severity of the condition between the group undergoing conventional therapy, and the other one in which group art therapy is used as an adjunct method would be necessary.

Conclusion
Group art therapy is considered a useful adjunctive method applied within the framework of the integrative approach to diagnosis and treatment of schizophrenia.It stimulates the development of creative potentials, building of self-esteem and self-confidence, along with destigmatization of schizophrenic patients, facilitating, thus, the integrative Strana 1069 Mandi Gaji G. Vojnosanit Pregl 2013; 70 (11): 1065-1069.therapeutic processes in a day hospital setting, and patient's social reintegration within the community.On the other side, its application enriches the whole diagnostic and therapeutic processes conducted by the psychiatrists and psychologists in a day hospital team, and helps understand the inner world of patients.Ostensibly simple, it is a complex adjunctive therapy, which illustrates the course of therapy and the patient's rehabilitation.Close observation of series of drawings might be useful for getting an insight into the effects and the course of integrative therapy for each patient.

Fig. 1 -Fig. 2 -
Fig. 1 -A drawing of flowers that looks depressed (the first patient, at the beginning of the treatment).

Fig. 3 -Fig. 4 -
Fig. 3 -A drawing of an empty house (the second patient, at the beginning of the treatment).