Creativity and the Dissociative Patient Puppets, Narrative and Art in the Treatment of Survivors of Childhood Trauma Lani Alaine Gerity Preface by Edith Kramerof related interest Art Therapy, Race and Culture by Jean Campbell, Marian Liebmann, Frederica Brooks Jenny Jonesand Cathy Ward 185302 578 X pl 85302579 8 hb Tapestry of Cultural Issues in Art Therapy Edited by Anna Hiscox and Ably Calisch ISBN 1 85302 576 3 pb Reflections on Therapeutic Storymaking The Use of Stories in Groups ISBN 1 85302 272 1 pb Arts Approaches to Conflict Edited by Marian Liebmann ISBN 185302 293 4 Creativity and the Dissociative Patient Puppets, Narrative and Art in the Treatment of Survivors of Childhood Trauma Lani Alaine Gerity Preface by Edith Kramer ® Jessica Kingsley Publishers London and PhiladelphiaAll rights reserved. No paragraph ofthis publication may be reproduced, copied or transmited ‘seve with writen permission of the Copyright Act 1956 (as amended), or under the terms of ted copying issued by the Copyright Liensing Agency, 33-34 fed Place, London WCIE 7DP, relation to this publication may be lable to claims for damages Any person who does any ut prosecution and cs ‘The right of Lani Alaine Geity to be identified a author of this work has been asserted by ber in accordance with the Copyright, Designs and Patents Act 1988. London Ni 9B, England and 325 Chestnut Stet, Philadelphia PA19106, USA. swohpcom Copyright © 1999 Lan Alaine Geriy Library of Congress Cataloging in Publication Data Geri Las Creativity and the dissociative patient: puppets narrative, and art inthe teasment of survivors of childhood trauma / Lani laine Gert. ‘cm, Includes bibliographical references znd index. ISBN 1-85302-722-7 (pb: all. paper) 1. Dissociative disorders — Treatment. 2. Puppets ~ Therapeutic se | Tide RCS53.D5G47 1999 616.85'23065156-de21 98-42739 cr British Library Cataloguing in Publication Data ergy Lani Aline, Creativity and the dissociative patent: puppets, narra survivors of childhood trauma 1. Arc therapy 2. Puppet making - Therapeuse we and ar inthe westment of ISBN 1-85302-722-7 Printed and Bound in Grest Britain by Athenaeum Press, Gateshead, Tyne and Wear Contents ACKNOWLEDGEMENTS 6 PREFACE BYEDITH KRAMER 9 1. Introduction 13 Population and Agents of Change 2. The Case of Jenny 23 3. Object Relations Theories and Application 63 4, Metaphor and Story 87 Anything Can Happen in Puppetland’ 5. Transference and Splitting 97 The Abyss ~ Self and Community 6. Healing the Split 105 Margaret, Winter Solstice and the Monster 7. Reparation and the Wise Old Woman 115 The Conclusion Postscript 123 Tying Up Loose Ends REFERENCES 135 SUBJECT INDEX 145 AUTHOR INDEX 149Acknowledgements would like to acknowledge my debt and gratitude to all my teachers, fa and friends, Not being able to thank everyone individually for everything they have done, I will have to pick a few from the many to acknowledge. Jenny and all of the passionate artists that I have had the honor of working with were very patient and inspiring teachers. Of my many instructors at New York University, Im particularly grateful to those who advised and guided the dissertation that preceded this book: Professor Laurie Wilson, Professor Robert Landy, and most especially Professor Edith Kramer for reading through this material so carefully, and gently pointing out how Kleinian language pathologizes normal developmental stages and inspite of that wrote such a wonderful preface would also like to thank Laura Silverstein for her support and advice. For of the puppet stories that came out of this work, thank you. Toby, without your curiosity about theory during those Jong evening discussions, I would never have thought of putting it on paper. Tam indebted to my entire family for theit encouragement and interest, but especially to Edna for urging me on during the more difficult times and to Edward for listening to endless permutations of thought and always asking the right questions and just because. In memory of William Gerity Jr.Introduction Population and Agents of Change ‘This book contains the lessons learned while working for more than a decade asan art therapist ina large mental health day treatment center in Manhattan. During this time I had the opportunity to work with many people who fell within a wide range of diagnostic categories, in both individual and group seiting, in art therapy groups as well as verbal groups. It was possible to see be correlations between diagnosis and preferences toward specific modalities of treatment. ‘The clients most drawn to art therapy seemed to have certain things in ‘common. These included diagnoses of borderline personality disorder, dissociative identity disorder (formerly multiple personality disorder), or post traumatic stress disorder. In addition, their early histories tended to include various kinds of trauma or abuse. were more open to art therapy than the mor Because I had run both kinds of groups and could see it wasn’ personality that clients were reacting to, I couldn't help but wonder wh: ‘was about the nature of art therapy that drew them with such intensity. 1 thought if I could work with an individual closely and examine the art work they seemed to immerse themselves in the language and metaphor of art making with more facility than patients with other diagnoses. It seemed essential to know what in the art-making process was therapeutic for this population. A therapist determining this could fine-tune her treatment skill, to meet the specific needs of the ‘adult survivor. ‘To that end this book includes a single case study of a dissociative patient, Jenny, who had a history of very severe early childhood trauma. Certain6 (CREATIVITY AND THE DISSOCIATIVE PATIENT aspects of art therapy were of particular therapeutic value for her. For example, she found puppet making and puppet play to be especially beneficial. It seemed that the psychological concept of reparation was occurring as she pieced together various components to create a whole Puppet, as ifthe external assemblage mirrored the process of psychological integration. Crucial to this process of integration was Jenny's role as puppeteer consciously orchestrating the cooperation and integration of her puppets/self. Another aspect of Jenny's treatment was the use of body image representations as @ therapeutic intervention. While a healthy sense of self contains a cohesive body self, Jenny's development was compromised by abuse and trauma, resulting in a less than healthy, cohesive body self. Within art therapy Jenny was able to work on the development ofa healthy sense of self by working with representations of body image In addition to Jenny's history and treatment, I would like to present some ofthe material, metaphors and stories, that emerged from other ‘survivors’ in 2 puppet-making group. By telling their stories, I hope to show how these individuals used what was in the art room to repair (or even generate in some cases) a cohesive, healthy, stronger sense of self and how this in turn led to a spirit of generosity and generativity within the community . the day I put my hands into the clay and started cre person who is very dear to me, something magical happened felta deep connection to a deep part of myself. I could put ahead ofa lay — my love, my anger, my fears and create a thing of beauty. My soul could be validated in an object look at and feel a deep sense of self-worth and even sel-love. And this, after allis the overall goal of my rehabi from jon — to learn to cherish and love myself ~ is everything else flows... when I created my clay head, I said, do this. I didn’t think I could. Maybe there are other things I can do. 48-year-old woman, survivor of cildbood sexual abuse Changes come so slowly that they are very difficult to see. Progress used to seem unobtainable; because seeing beyond ‘right now’ requires a different vision, one that I never seemed to have before art. Five years ago, I was trapped in my mental illness — going from one doctor to another, so disabled by my own mind that I could no longer function in the outside world, I was desperate to break free, to find some way to let someone know how I felt, what was going on in my head. But had no INTRODUCTION 15 words. Then an art therapist gave me some clay, some pastels, paper — less than arduous, undertaken in addition to my dai ing my way back to realty and hope. Artis my world, and yours to mine. 30-year-old woman, ritual cult survivor 38-year-old man, survivor of childbood sexual abuse ‘These words were written by three individuals who were trying to express ‘what they found of value in art therapy they received atthe centre. As one of the art therapists working with these individuals, I was moved by their passion, but also curious. I wondered what it was about the nature of art therapy that these particular clients are so drawn to it. ‘The three clients above talked about the various ways that art therapy helped them. Working fairly closely with them, I had the opportunity to ‘observe two things about these clients, who were fairly typical for this traumatized borderline-DID continuum. The frst thing I observed was that they were very passionate and seemed better suited for the art room than for verbal groups where their passions seemed continually to get them into ‘rouble. The second thing I noticed was that they seemed to use art materials in a reparative manner, but I will address this further along. ‘The population named ‘chronically and persistently mentally ill by the State of New York was the population our center treated. The persistence of their symptoms made them a difficult population. The survivors of early childhood trauma were, in our agency, a subgroup of this more general population, and because of their traumatic histories often had uniquely difficult interactions with staff. Their histories were often so horrific that the therapist could easily lose a sense of objectivity. In an effort ro balance the perceived horror, staff might be tempted to treat the patients as very special. ‘The well-meaning therapist may make every effort to counter the negative(CREATIVITY AND THE DISSOCIATIVE PATIENT attention the patient received in childhood with positive attention. es the feeling was that al a particular patient needed was some love or affection, and that the therapist understood this where no one else ever did — indeed, often feeling, as one intern described, a ‘special thread of singling out, ot ‘specialness’, within the family structure that contributed to the problem of abuse or trauma, Such individuals are always alert to the behaviours of those they perceive as being ‘in power’. They are alert and pethaps expectant. Unwittingly, the therapist may begin to treat the patients in exactly the manner that they expect. Often, very well-meaning therapists themselves in positions of being a hated object and with such volatile, passionate individuals this can be extremely diffi In my observations, as you will soon see, creative arts therapists are fortunate to have objects and imagery to work with which often seem to absorb and drain off these excess passions. Objects and imagery become the focus for both patient and therapist. There is an investment of positive feelings in the ‘transitional object’ or the artwork and the transitional space, lace where the artwork is created. Because attention is not directly focused on the patient but rather on the productions, the patients often spoke of feeling safer in the art room or the pottery room than anywhere else in the building. Unwary art therapists and other staff might begin to think or believe that these positive feelings are caused by the art therapist's personality or her great efforts to understand the patient, leading to storms of countertransference. I suspected, however, that the facility these patients hhave in the creative arts and the feelings of safety that they express about the art room have less to do with the personality of the art therapist and have more to do witha fit between the needs of these individuals and the agents of change within the creative process. But why look at the reparative qualities in art therapy, as seen specifically in the realm of body image? This was the second thing that I noticed about these patients, that they would often q ally create various human body parts and make a whole of them, repairing the self-image or pethaps repairing the image of a loved one as quoted above. I think this can be best od in terms of their histories of abuse, neglect and trauma to their selves, how they carried physical memories which were reflected in their sense of self as a body. They expressed a feeling of being damaged, a feeling of being not an integrated whole body but a sum of odd, unrelated INTRODUCTION a parts. One patient said she generally felt her left hand didn't know what her ght hand was doin; °F serestingly that | feeling was recreated in the staff who worked with these , as if we were enacting their inner dramas. We could easily replicate the lack of integration among ourselves, in much the same way the patients would describe their inner worlds. Sometimes a therapist would simply find a patient intolerable and ask to have him or her removed from their group (usually a verbal group). Herman (1992) commented on this phenomenon, noting that adult survivors of childhood trauma ‘evoke ‘unusually intense reactions in caregivers’ (p.123) T became very interested in how this creative process unfolds, how the healing and reparative qualities of art therapy worked for this population. 1 wanted to understand the effects of childhood trauma as well as what helps these individuals and why. In understanding of how positive change occurs ‘we also learn more about using our craft. These patients seemed to tolerate art groups, get along better with their peers in them, and even thrived in them, ‘while continuing to be disruptive in verbal groups. It seemed that art therapy provided something that might not have been provided in any verbal ‘modality Is it that it engages the patient in reparative work on a preverbal level? Much of the trauma that occurred for these patients occurred before they had developed language, and it may be that having access to preverbal imagery is a particular strength of art therapy. Art therapy provided a place ‘where the patient was able to return to the memory of early bodily traumas, now held within imagery, and provided the tools to express and change the ‘meaning, intensity and intractability of the imagery. A patient was now able to begin to repair the damage done to his or her body image on a preverbal level, in a way that talking could never facilitate. his book is about Jenny and a few other patients with similar passions and history of trauma. It is about their work to overcome the influence of the past in their present lives. Like many with a history of early childhood trauma, Jenny had a sense of self so fragmented that she gave names or labels to these various fragments, dissociated feelings and aspects of her personality (Carey, Joy and Jenny). Her artwork showed this same dissociation. Body image representations in the beginning of treatment were incomplete or in pieces, sometimes heads floating in space. Looking at body image representations to understand better the patient’ sense of self is not a new idea6 CREATIVITY AND THE DISSOCIATIVE PATIENT Kramer (1993) stated that ‘children's artis above all self representation’ (279). She described evaluating a child’s body image through his sculptures; a child who was reluctant to sculpt people, but ‘the few attempts he could be induced to make proved that his body-image was intact and free from gross distortions’ (p.79), Krueger (1989) stated that the body image representation or projective drawing will be an arbitrary slice from the ongoing process of maturation, since one's body image evolves during one's life. He felt that in the course of successful therapy one can see clearly the process of maturation and dis ing developmental maturation, Concurring with these observations, I believe body image representation can be used as the measure of change, based on the hypothesis that it was an expression of the patient's sense of physical self. The body image representations of the people I worked with contained within them expressions of fragmentation, or pain, and then a sense of being soothed, or of which will be shown later Il be examining a course of treatment, looking at the artwork produced and ining a course of treatment cannot be entirely objective since the author's personal bias is bound to influence the examination. Although research may be conducted rigorously and with care, therapists have to be particularly alert to bias introduced through the phenomena of transference and countertransference. Our day ‘treatment center had its share of transference and countertransference issues, an ongoing factor in treatment, and of which many examples will follow. tas the good person good-enough mother would feed the child and reduce its stress. The verbal counselors often received negative projections because they were increasing the patients’ anxiety and stress by verbal questioning, which was often experienced as prying or invasive, much as an abusive parent might invade a child's physical being and increases the child's stress. It was easier to experience empathy for the patients if one was the receptor of positive transferential feelings. At our agency, the patients’ negative feelings towards those who were less than sympathetic towards them could be observed, as could the tension and controversy that occurred among staff when such transference and countertransference came to the fore. Another aspect of subjectivity in this kind of book isthe reality that as a therapist I had an investment in a successful outcome and thus was rarely INTRODUCTION 9 simply a disinterested observer/ writer. However, I found that a great deal can be learned from the therapist's reflection on the therapeutic process, the basis of a hermeneutic approach to learning. ‘The center ‘When Jenny arrived at the mental health day treatment center in the 980s, it served 500 of New York City’s chronically and persistently ion given by the State of New lumped people together who, Iness and their symptoms, couldn't maintain work and ithout support. These 500 patients came in for group At this time, the center because of men the place in society : ‘ 1 ividual therapy and to see a psychia a uychodytami my based with a very creative team of drama, dance and art therapists who were responsible for most of the group work done there, During brainstorming sessions we would develop ideas for new groups, share some new creative idea that came from a conference, or suggest in a group. Of course, this was before our to look at fiscal concerns over and above other concerns. We ‘The center was housed in a former church building. The art oom was converted from the pastor's study, complete with ‘oak bookshelves, an oak window seat and leaded glass window panes. The free wall space was covered with particle boards which allowed patients to display as much of their artwork as possible without damaging the walls, All of the art supplies were accessible on the bookshelves, and we encouraged patients to take responsibility for the materials as well as for their artwork. We had one very large table that seated 15 people and one separate table for had difficulty being in a group. 7 sara hie -making ae vi eld inthe art oom. The idea for shad come when I had observed a painfully shy young man complete a drawing of a beautiful woman and then take it to the full-length mirror, where he began playfully talking for it. Observing this, l asked questions of the picture and he easily answered through the picture, all signs of reticence having mysteriously disappeared. It was a light-hearted but, for me, exciting moment. It became clear that this reserved patient could more easily speak through a picture. The thought occurred to me that he and others might benefit from a puppet-making group where they could talk and play out various stories while working on body image representations.20 (CREATIVITY AND THE DISSOCIATIVE PATIENT During this time, there was also a separate room for pottery, complete kiln, tools, clay and long tables at which several patients could work together. The pottery groups were run like open studio groups, less tured than art therapy, so patients could walk around the tables and talk to one another about work in progress. place when Jenny arrived at our center had many creative options and possibilities for reparative work. Defining reparation and body image ‘The term ‘reparation’ was used by Melanie Klein (1921) to indicate a psychological process, something more than the making of amends. She believed a young child will have many aggressive and sadistic feelings that she will project onto her environment. The ch en sense 2 need to create reparative gestures towards the damaged world in an effort to not be persecuted by it. As the reparative gestures reduce anxiety, feelings of gui and constructive tendencies are able to come forward. With the patients like Jenny, though, it was much more than the world that had been damaged, was their very selves that had been damaged and betrayed. These patients hhad internalized the traumata or abuse and continued to damage themselves. Clegg (1984, 1995) broadened the definition of reparation to include the self. He believed that gestures could be made towards the damaged world and towards the damaged self through various creative arts therapies turning this figurative gesture into something concrete. In our art room and pottery studio this repair of the damaged self could be seen in the integration of body image representations, thus for our purposes the term reparation will refer to the psychological process as well as its representation in the of what has been damaged. ‘What do we mean by body image? For this discussion the term refers to the inner sensations and peripheral awareness that form the bodily experience of the individual. This would include the feelings and concepts that individuals have about their bodily experience which change and develop throughout their lives. Feud (1923) defined body image as a deposit of internalized images encompassing the self-representations and internalized representations of the loved object. Niederland (1967) described the concept of body image as being of central significance for the understanding of human personality growth. He saw body image asthe felt ‘experience of the body, the sum of personal, pervasive experiences which are derived from the interaction of postural, kinesthetic, physical functions with al repai INTRODUCTION a the sensorial, perceptive, emotional, cognitive functions. He proposed that it interaction which provides the coherent and cohesive backdrop for cegrated ego functioning and for the development of grat ions in later life, From this we can easily see the importance of early bodily experience in the formation of human identity. Ifa patient had very ne ego functioning, and would have impaired object relations in later life. But given the ability for feelings and concepts to change, reparative work was a ity in our center with its strong creative arts program. A note on the theoretical framework of this book My clinical work has been most influenced or affected by the theories of Freud, Winnicott, Klein, as well as the current theorists, Ogden, Giovacchi Grotstein and Bower, who discuss developmental disorders in terms of object relations, internalization and projective identification. Object relations theories speak to the issue of how we as humans develop a sense of who we are in the world. There is an acknowledgement of the fact that we internalize images of those who are important to out development, that we carry these images around with us and project them onto others and onto new situations. Object relations theorists focus on development of self through the internalization of images. They propose that we contain at our core images of what is and what was around us. It is through this collection of images and internalizations that we learn who we are. Asa student of Edith Kramer and Laurie Wilson I was given a firm foundation in the healing potential of the creative act itself and I found that object relations theories shed some light on ‘why the creative act is healing, ~ “Art therapists working with individuals who have suffered early trauma can easily see these projections ‘ernalizations because we have the luxury of being in a space which encourages the free expression and play of images and imagination. I found object relations theories satisfying in that they provide a way of examining and thinking about human development and imagery, a context and language with which to understand how humans create imagery and symbols. Moreover, they speak to questions of agents of change, thus I have relied heavily upon them as an explanatory model throughout the present analysis. In addition to Jenny's history and treatment to presentsome of the material, metaphors and stories that emerged from other ‘survivors’ in2 (CREATIVITY AND THE DISSOCIATIVE PATIENT the puppet-making group. By examining these stories in addition to Jenny's, Thope to follow the path these individuals took to repair (or even generate in some cases) a cohesive, healthy, stronger sense of selfand how this in turn led (0 a spirit of generosity and generativity within the community, which presented a further layer of healing for these ‘adult survivors’. The Case of Jenny 1 began working with Jenny in September of 1985. Because of early childhood experiences, Jenny's sense of self was fragmented and inconsistent, but I didn’t know her history or her changing sense of self ‘when she first came to art therapy. My initial impression of this 40-yeat 300-pound, African-American woman was of a simy individual, a litle frightened and somewhat clinging. In the art room, she always sat as close as possible to the door. When I would. would also sit near the door to have a certain amount of influence over the comings and goings. I wasn't sure if Jenny wanted a quick escape route or her drawings were p her environment, flowers ings done in avery c ‘which she seemed compelled to always place barbed wire (Figure 2.1). This image of barbed wire repeated itself over and over, and was the first indication that perhaps Jenny's story was not as simple as it fist appeared. It was in the pottery studio that I observed Jenny's manner change. She exhibited excitement and enthusiasm. She didn’t giggle shyly, but seemed ‘more mature, more confident. She seemed to have more mastery over the materials when working with clay and, perhaps because of the mastery, more pleasure. She moved about the room easily, not needing to be proximity to an escape route or the art therapist. Typically, she would create breast-shaped containers that after much working and smoothing would become mugs. At first I dismissed this change of behavior as being related to Melanie Klein's theories about the breast; that somehow the pottery studio represented a source of ‘comforts, physical and me reservoir of food and warmth’ (Segal 1964, p.40). In explaining Klein's theories, Segal states that there isa blissful experience of satisfaction that this, ‘wonderful object, the breast, can give and that the infant desires to possess4 (CREATIVITY AND THE DISSOCIATIVE PATIENT “THE CASE OF JENNY as Figure 2.1 Cityscape with barbed wire and protect it, but also longs to be the source of this perfection. Segal could hhave been describing the pottery studio. I had observed many patients working with clay. More offen than not they responded to the soft, comforting material, molding it into a desired object. It was malleable, flexible and the barrel in which the clay was kept seemed bottomless, inexhaustible, Patients possessed the material, created something new wit and found themselves to be the source of that perfect moment of creation. I had observed the harshest, most hostile of patients almost miraculously grow pliable in lay in their pottery studio. ‘The art room, however, was a larger room, full of sharp edges, uncooperative materials and memories of teachers who told students they couldn't really draw. I thought Jenny might be responding to the difference in the space and the memories it might evoke. I could not continue to ignore Jenny's changing behavior for long, however. During one session late in the fall of 1985, Jenny created a soft mound which she smoothed and stroked with water, an activity that clearly resembled symbiotic contentment. Suddenly her mood changed. She wanted atool the mound with holes, to make a pencil holder. She could not be dissuaded and the mound was attacked with what looked abandon. At the end of this session Jenny Figure 2.2 Pencil bolder ‘would be seeing her psychiatrist again after the psychiatrist's six-month maternity leave. It would seem Jenny made an association between the breast shape and the therapist who had deprived her for six months. Itbecame vi that she fill the breast full of holes, discharging her rage with a certain amount of regulation and control. It was also vital that she then turn this into something funct the rage could be expressed but transformed into a gift, a pen ‘The next session with Jenny was in the art room. She seemed to be busy creating and destroying a large black tear. She would almost complete one, destroy it and try another. During this process Jenny stated that her stated that her therapist had told her to trust her, that she would come back after having a baby. ‘Why did she have to go and have a dumb old baby, anyway?’ As Jenny colored the tear with black ctayon and ran barbed wire across the picture, she stated the tear didn’t mean anything, that she wasjusta and she really couldn't cry. At this point 1 resemblance between the tear and the clay ‘pencil holder’, so Is tear looked like a lot of ‘bad stuff; bad mother stuff or bad psychi Jenny responded to this with the association of her first memory of wanting2% (CREATIVITY AND THE DISSOCIATIVE PATIENT to die, oftaking a bottle of aspirin, of being told by her mother that she could stay with the doctor for doing that. She made a further association to a time ‘when she was four and her mother left her on the steps of City Hall, but the courts made the mother take Jenny back. When questioned as to whether ot not such memories might not make Jenny a the tears she drew belonged to ‘Carey’, who pretty and had it all together. The chart After this session I went to the chart room to check Jenny's diagnosis and ory. (Seeing as many people in a week as we did, lam embarrassed to say charts were only read after something remarkable occurred) Her chart contained a detailed report from a referring agency and seemed to be material taken from interviews with her. It stated that she was third of seven siblings and had often been beaten by her mother and siblings. This was justified by a story that she had been adopted, a story which she had not questioned until she was 12, Her first suicide attempt was at the age of three, following the death of an uncle, She had seen him lying peacefully with a smile on his face at the funeral. Around this Id her never to take more than two aspirin or she would be dead like her uncle. Jenny had felt it would be better to be dead than alive and continually beaten by the members of her family. She reported that while in the hospital having her stomach pumped, her mother had tried to get the doctors to keep her. At the age of six Jenny developed migraines after her father had tried to Kall her by choking her. He said he would kill her ifshe ever talked about it. She also reported having been raped at this time. She began therapy at the age of eight. Atthis point the chart began to include references to gaps in her memory and a that she couldn't understand. When her father lay dying in hospital with cancer ofthe esophagus, Jenny visited him every day for two years. She didn’t know why she felt compelled to visit him, since each visit was so painful. When she was in twelfth grade she began a six-year stretch with a therapist at Bellevue Hospital whom she reported she never said a word to, During the seventh year the therapist lef the hospital and Jenny tied to commit suicide. During that period she went to City University ‘of New York and got a BA in sociology, but she had no memory of college at all. Jenny had then worked for the telephone company for three years but was red for migraines, dizziness and writing numbers backwards. She also worked in a church-run day care center but was fired and brought up on “THE CASE OF JENNY a charges of arson and then was acquitted for lack of evidence. She reported a history of, once a month, since her adolescence, stealing things that she didn’t want or need. Jenny reported hearing voices of men and women inside her, telling her she was bad. The chart gave her diagnosis as paranoid schizophrenia, but the history of child abuse, migraines, dizziness, periods of amnesia, a chil suicide attempts and hearing internal voices were all indicators of DID (at that time MPD) (Kluft 19852). (Jenny's psychiatrist later admitted that the choice of diagnosis was simply the justification for his choice of medication and treatment) The treatment In order to look at Jenny's use of art therapy I will summarize the work that ‘was documented along with her reactions from early spring of 1987 to late spting of 1988 (Gerity 1997). This will provide an overview of how a dissociative individual is able to use art therapy. Hypotheses about the actual agents of change could be inferred from this overview. I had been working with Jenny for a year and a half by the spring of 1987 and had established a positive rapport. She seemed fairly comfortable in both the art room and the pottery studio. She had joined the puppet-making group, where various parts of herself began to emerge more clearly. (Over the years this puppet-making group had various co-leaders, usually drama therapists or interns in drama therapy and art therapy. It was our task to maintain a group that was fluid and flexible enough to allow for the patients to create various characters out of papier maché and cloth and to then imbue them with story and personality. We were also responsible for keeping clear boundaries and limits, so that the group would be safe from the annihilation urges of a destructive puppet, a representation of an internalized ‘bad object’. In order to maintain the balance between fluidity and structure, swe would create puppets alongside the patients, neutral puppets or puppets that had some mythic qualities on which the group could project free ‘Through these puppets we could encourage imaginative play wt maintaining a sense of group structure, ‘At the beginning of each puppetry group the patients would retrieve their puppets from their little shoe box homes, painted and stacked in one of the bookcases. During the session some members would be working on puppets, creating, fixing or remodeling, while others played and interacted with one ‘another. At the end of each session, the puppets were carefully returned to2 Figure 2.3 Erie (CREATIVITY AND THE DISSOCIATIVE PATIENT. Figure 2.4 Joy “THE CASE OF JENNY » their isle homes. The puppets were treated like very special objects. 'd even heard the humming of alullaby upon occasion as the shoe box was put back on its shelf, “The first puppet Jenny created was a male puppet, Eric, arepresentation of her psychiatrist (Figure 2.3). Eric was extremely wise and thoughtful. Before he spoke there was always a pause, as if he were thinking about how best to phrase his utterances. His wisdom and calm demeanor were admired by all and soon other patients began creating representations of theit own wise psychiatrists as wel ‘The second puppet to be created was Joy, who represented that part of Jenny that was actually being treated at a separate agency (Figure 2.4). This other agency was predominantly a creative arts rehabilitation center and Jenny (or Joy as she was known there) saw two music therapists for individual ‘treatment. This personality-part, Joy, was very childlike, sweet, outgoing and loved to sing. She would appear at our center whenever there was a talent show. The puppet reflected all of these qualities. Perhaps because this puppet and the personality-part it represented seemed to be so easygoing and without problems to work out, or perhaps because Joy was in treatment at another center, we didn't see as much of Joy the puppet as we did the other Puppets. ‘The third puppet created was Carey (Figure 2.5). Carey represented that part of Jenny that was very difficult to be around. She was self-centered, spoke loudly, and didn’t care what people thought of her. Her dress was @ beautiful patchwork of fiery red and she had little red star earrings. She was as strong and sure of herself as Joy was sweet and self-effacing. ‘At this point in the puppetmaking we began to see Jenny experimenting and actually becoming more confident in her work. Lisa was created, with a handkerchief apron and an extremely large baby to take care of (Figures 2.6 and 2.7). Lisa was a representation of Dr Lisa, the psychiatrist who had gone on maternity leave. At the time Jenny made Lisa, she was actually being treated by Eric and awaiting Lisa's return. Lisa's baby was a puppet at least as big as his mother. He had a fully formed, open mouth and ali the group the bottle ‘was seen metaphorically as bad, too small, so I created one out of paper that was three times the size of the puppet, which delighted Jenny no end. The nature of this group made it possible to address these needs and issues through non-threatening metaphor and interactive ‘One can2 (CREATIVITY AND THE DISSOCIATIVE PATIENT needy and acting what I was sayin ‘A puppet we saw a great di ‘of was Mr Mad, also fire-engine red (Figure 2.8). This was a very phallic finger puppet, with no arms. He was forever rapping his hard little head on the table in annoyance, giving himself headaches. The other patients delighted in his anger. He so e: some of the things they wished to express but didn't dare. Because he had no arms he was not seen as 2 real threat to anyone except himself, when he got the urge to rap his head on the table. When asked what he was so mad about he said he didn’t really know. One patient pulled out his own psychiatrst/ psychoanalyst puppet and a couch comp! pillow, and offered his services to Mr Mad to get to the root of his ‘madness’ Mr Mad agreed, free associated on the couch and, through possibly the fastest psychoanalysis on record, learned that because he had grown up in a completely mad family, where everyone was mad all the time, that was what he learned to be. Margaret was seen as very different from Mr Mad (Figure 2.9). She was seen as a very threatening puppet to most of the group members but especially to Jenny. She was a representation of Jenny’s mother. She was made with the most care, with tiny carefully painted features, gold earrings, hair that was various shades of gray, and a beautiful blue patchwork dress with a piece of embroidered handkerchief at the center. She, for the most part, stayed hidden in her own shoe box with a jailer or keeper puppet that I had created (Figure 2.10). This puppet, Sebastian, was named by Jenny and given his function by her as well. He was to keep the other puppets safe from Margaret and Margaret safe from them. Finally, the puppet that Jenny was working on in February of 1987, when | began to document our work together, was Lita, a representation of her counselor at the center (Figure 2.11). Lita had a sweet, open expression on her face and was a good-hearted puppet representing a good-hearted counselor. Around that time Jenny (or Joy) had taken her puppets to the center where Joy received treatment to show one of her music therapists. While explaining to the therapist who each puppet was and who they represented, she realized forthe fi they represented African-American people but in actuality they represented white people, while the puppet representing Lita, a white counselor, looked like a white person. Jenny/Joy was baffled how she never noticed this glaring visual ‘mistake’. wooden anal ‘THE CASE OF JENNY Figure 2.9 Margaret Figure 2.10 Ses“ (CREATIVITY ANO THE DISSOCIATIVE PATIENT Figure 2.11 Lite As Jenny became more comfortable in the art room and became more expressive with the puppets, some awareness of object constancy emerged ing that she didn’t have to rush through things to try to get something done all at once, that she could put things away and come back to them. She was beginning to trust that she could come back to things. She reflected on the importance of flexi ‘You can't expect things how things are going to turn out the more enjoyment you get,’ she sai ty 1997, p34). T noted, though, that Jenny was struggling to understand the idea of 3, a very difficult concept for ent who prefers to wall off various feeling states. In the puppetry group she was again using Mr Mad and talking with the drama therapist's depressed blue finger puppet, Hound Dog. Hound Dog explained that the drama therapist was making a new puppet and so he was depressed, hhim some energy, to which Hound Dog responded he was all blue and couldn't feel anything except blue. Being the ever-vigilant art therapist, always in search of a visual metaphor, I rooted around in some felt pieces r tuntil | found a little red heart, which I quietly brought over to Jenny, not ‘wanting to interrupt the process. Without missing a beat Mr Mad asked Hound Dog if he wanted to feel mad, that fhe had a red heart he could feel ‘other things than blue. Hound Dog was pleased with this solution, so Jenny glued the litte heart onto the Hound Dog puppe Mr Mad if he didn’t need a blu feel other things besides mad, to ‘which Mr Mad responded gleefully ‘Yes’. Back I trotted to the felt scraps for alittle blue heart which I gave to the drama therapist who then glued it onto Mr Mad. Jenny seemed delighted with this interaction, and the drama therapist and I certainly were happy with this acceptance of two distinct feeling states in the one puppet. We saw it as opening the way for learning tolerance of ambivalence. Later that spring, Jenny and several of the other puppetry group members learned that their counselor was leaving the center. Jenny had just finished her Lita puppet. A discussion ensued about some of the patients feeling silly playing with puppets, feeling like kids. Jenny was looking down at het puppets and she said she took them very seriously. They continued to talk. about how sometimes it was very embarrassing to speak through the puppets and to find the puppets saying the most awful things, and that sometimes the puppets spoke more openly and honestly than they were comfortable with. ‘Then the discussion turned to the counselor's leaving, Jenny offered to put the puppet (representing their counselor), into 2 large cardboard box painted black with ‘City Dump: Home for Bad Puppets’ in white letters on the side, This box was created so that a puppeteer could discard a difficult part of herself without destroying the puppet. The patients quickly forgot their resistance to playing with puppets and discussed all the options for visitation rights and which puppet would check on her in the dump on a regular basis. They seemed to be deeply involved in this way of hol their beloved counselor and expressing their anger with her as, After that session I decided to try ing Jenny's puppets outside of the puppetry group. This was a completely novel concept, based on a time-tested qualitative research technique, but with a twist. 1 was not interviewing the subject directly, but interviewing characters or personalities. represented by or projected onto her puppets. We used a tape recorder, and Jenny understood the tapes would be part of the research documentation I was doing at that time. During this in level of competence in child rearing, She gave her puppet Lisa advice on how ‘THE CASE OF JENNY 5 interview process Jenny was eager to express a certain6 (CREATIVITY AND THE DISSOCIATIVE PATIENT to care for her two-ye patient and everything will work itself out.’ This advice seemed direct opposition to the way she was raised, to the things she had learned from her own childhood. I recalled Mr Mad's madness being something he had learned from growing up in a completely mad family. During the heart of a happy color, What started as an attempt to obtain information, interview tape recorder, met with such success that it evolved into a therapeutic tervention, a staple in our therapeutic relationship. I transcribed our terviews and often gave Jenny excerpts of particularly insightful sessions. ‘This was another way of softening the barriers between feel Personality-parts. These interviews were a way to reach an extremely guarded person. This was a window out of which Jenny, Carey and Joy could ‘observe the world and a window through which they allowed me to interact with them, Although it was a way to reach these various parts of her personality, one should keep in mind that Jenny was playing puppeteer. She was identifying with the person who is in control of a characters. She was allowing me to approach her, and her dissociative identities, ina respectful and serious manner, but because puppets were being used there was also a crucial element of play, of the unexpected, and of possibility for change. During the summer, while reviewing a log I had been keeping of Jenny's work, I noticed that in the pottery groups Jenny would often approve of something she was working on and then, almost in the next breath, would disapprove and sometimes even destroy her work. After a moment of pride she would express a destructive kind of criticism. I wondered if it was something in her relationship with Margaret, her mother, that caused her to attempt to destroy that thing that made her happy, which I wll explore later. By keeping a log, observing behaviors and changes over time, I was able to question Jenny about them either directly or through the metaphors that art provided. An example of this was being able to elicit from Mr Mad a \gness to try yet another feeling and another color of heart to go with. Subtle changes could be observed, documented and enhanced through thi log-keeping process, something that could not necessarily happen with all of Pr ‘THE CASE OF JENNY the other individuals in groups. Therapists had to keep alert to many and often subtleties would slip past one. ‘That summer Jenny began a journal that she kept in my office. I she had wanted it to explain more of who she was and how she came to her current life situation. The first entry was written during the entire month of ithout notation of dates, and contained her entire history written in hher words. There were many statements full of despair and hopelessness. This journal became an additional source of communication. She could write about her reactions to the things that occurred in ar therapy. At one point she ‘wrote that pethaps having her own puppets at home would be of more comfort to her than her stuffed animals, because she had made them after all and they had their own personalities, very real personalities that had taken a lifetime to develop. I believe she was realizing for the first time that she was actually responsible for her own satisfaction. I made note of the idea of her wish to have something at home and was able to put it to good use, which we vill see shortly In early fall, Jenny's psychiatrist (Eric) talked with Jenny's new counselor and together they decided that Jenny should work with her puppets to bring ‘out more cooperation between Joy and Carey. Iwas enlisted in this effort and to this end I interviewed the puppets Joy and Carey and attempted to discuss the concept of cooperation. Carey let me know in no uncertain terms that keeping things separate, keeping Joy and Jenny in the dark, was very important to her. She even said she liked to hurt Jennyy and Joy, giving Jenny migraines for example. She said, ‘Iam evil and I like to hate. I see things in black and white’ (Gerity 1997, p38). Although at first glance the session did not appear to go well, because we seemed to be working with Eric's agenda rather than Jenny's, I now gota clearer idea of the internal dynamic between. Jenny, Carey and Joy. That fall Jenny's concerns about her suicidal roommate Sally emerged. Sally was a very big, blonde woman from the Ozark mountains. She and Jenny had met during a hospitalization and they discovered t! quite a bit in common; histories of abuse, various ‘other peop! them and a love of food. They decided that they should room together and. save some money, both being dependent on public assistance. They also both received music therapy from the other creative arts center. For a short time Sally attended our center as well, but didn’t like the scheduling of so ‘many groups and activities, so she ‘let’ Jenny have this space for herself.28 ‘CREATIVITY AND THE DISSOCIATIVE PATIENT ‘THE CASE OF JENNY ”° However, being ‘allowed’ to have one's own space seemed to be a growing ao her parents (or the uninvolved par in puppetry Jenny talked about her roommate's threatened suicide. Both | wasanother precursor to the masoch the drama therapist and I asked Jenny's psychiatrist puppet about the issue of | some report of the trauma would then be perceived as an act of hostility destructive and dependent relationships between our various puppets. Jenny's psychiatrist puppet spoke eloquently about the need for gradual Practicing of independence, that if one puppet leaves for a short period of now what is happening to her and that something will be done without her time and then comes back the other puppet can learn that just because one | faving to break her silence, just as she had wished that the school system leaves for a while doesn’t mean that one has to leave for ever. Later in the | Could have seen her bruises and done something. There were references in session, Jenny stated she didn't know why but puppetry made her feel better. | er writings about not being able to take much more of the demands of, 1 pointed out that our puppets’ problems were si family pressures, but there was no understanding that she would have been her roommate and that the psychiatrist puppet had helped find a safe ifshe exercised control over these pressures. There was only the passive Solution and that solutions to problems sometimes make people feel better, | wish that these pressures would go away, that someone would kill her or that giving them a sense of inner satisfaction, she would die A constant refrain in Jenny's journal writing at this time was the suffering Lister believed that this pattern of trauma may begin at an age when some and pain of her present situation that she went through in silence. In reading | gegree of merging with the ‘perpetrator’ is developmentally normal. To Lister's (1982) article, ‘Forced silence: A neglected dimension of trauma’, a | rea this bond by speaking of the trauma requires the ‘victim’ to separate discussion of the reluctance that a victim has to speak, I was struck by the | from the ‘perpetrator’ which may feel like an impossible loss. Rather than similarities ofthe case material and discussion to what was emerging With accept the loss, the ‘victim’ will tolerate abuse, remain in physical or Jenny: ‘... the consequences of having been traumatized cannot be ... | psychological ‘bondage’, and honor the command for silence, remaining understood ... outside the context of their profonged silence after the event. | Cigse enough to attempt to ‘cure’ the parent (Lister 1982) jing a masochistic stance. Li In silence, the pain and subliminal memories of pain festered’ (Lister 1982, ‘Although Jenny reported hating her mother, she continually, 873). This was a constant theme in Jenny's writings. There was an internal | pjease her. Any threat of loss or separation was seen as an attack and usual pain and anger that was festering and growing out of control. ‘Ifa victim | sige in Jenny acting out this ‘attack’ in some way, usually with a somatic {ooks for help, or goes further and recounts the trauma, there isasense that complaint. She stated that she felt that her body was leaving her and slowly has been broken, that retaliation becomes possible orlikely oreven breaking down. “To understand these cases and apply what we have learned (Lister 1982, p874). In Jenny's chart there was the reference to | hout trauma in general, we must rea a therapist spent in silence. She was probably terrified to speak about her history. She sometimes seemed to need co sulk silently in groups, and with Lister's article in mind 1 would hand het paper and pen the power of the threat and the tenacity of the victim's psychological relationship with the victimizer (Lister 1982, p.875). This was not only true for Jenny's rel ‘mother and Sally, but was also true for her internal relationships. that the prohibition to keep silence might not include art or writing. Usually ‘The issue of body image and weight were a central theme that the paper and pencil were used to write out the inner dialogues that were puppet interview, Joy admitted Jenny was terified to lose anything, even a troubling her. It certainly seemed tobe easier for her to write these dialogues Single pound. Duting ths interview Joy described her arrival in Jenny's life, than to talk about them in group. at the age of six when Jenny was raped. She believed Jenny needed to be Her chart described her father's threat that he would killher ifshe talked | eavy eve since that time because men would then find her less desirable. Joy about him and in her writings she expressed threats of pain and domination wasn't so sure that that was necessary any mote fom Carey ifJenny talked about her. Lister believed that threat, vulnerability, In the art room these body image concerns were put into her creation of| the fear of repetition and a self-protective compliance form fertile ground for full body image representations in the form of dolls. She had made0 (CREATIVITY AND THE DISSOCIATIVE PATIENT papier-maché heads, hands and feet, She began to cut out litte fabric bodies, bbuthad cut one too small, She then had to re-cutit and began free associating to the vulnerability of her pottery and her own body. After expressing these concerns she then successfully created a cloth body that matched the hands, head and feet, as if expressing the concerns and fears was helpful in the resolution ofthe doll’s body. The cloth was now able to connect the separate body parts, making a whole body image representation. This was an exercise in putting together, in making whole, and a very different thing from her journal writings, which were filled with references to internal splitting and) attacking of self and body image. In pottery I pointed out to Jenny that her slab work was related to the ‘that she was putting pieces together to create something not to mention beautiful and useful, She wrote in her journal about the feeling of control she had when measuring and fitting the slabs. together She also expressed the fact that it took her full attention and created a soothing feeling, She described creating pinch pots as also being a way of slowing down and focusing, watching 2 form slowly emerge from the clay. Sometimes, however, Carey would step in and destroy a piece. She wrote that then feel so bad she would feel self destructive. She fet she had no control over Carey's destructiveness. But the reality was that for her, clay was very therapeutic, either pinching or building with slabs, and she intended to continue working with it even after leaving the center, ‘by whatever means ty thoughts in reading this I told her, were that everyone had their own role and even Carey had the role of critic and that she didn’t need to feel hurt or self-destructive when Carey was critical, since Carey seemed to want everyone to do their very best. In an effort to understand the helplessness that Jenny and Joy expressed about Carey's destructive urges, I tumed to Krystal’s (1978) and affects, a clear discussion of the feelings of helplessness, the difficulty in verbalizing concerns and the need for somatization of victims of trauma. Krystal reviewed Freud’s concept of trauma, suggesting that the feeling of helplessness was key to understanding why a situation is traumatic. The ‘traumatized individual feels helpless, feels that his or her own strength is inadequate for the situation. This is a reality for children who are being abused, Their strength is inadequate to defend themse Krystal po ere was an accompanying it emotions and that these emotions were then expressed in psychosomatic ‘THE CASE OF JENNY 4 and arthritis. This kind of expression, representation, he considered to be a ‘regression in affective expression’ (p.95). We can observe this psychosomatic disease process in Jenny, in her ‘constant quests for treatment of somatic complaints. She had many doctors ies all over Manhattan. One cardiologist told her she had to lose weight, another doctor told her she was losing too much ‘weight too quickly, and that she would be in 2 wheelchair for the rest of her fife. She saw a specialist for her arthritis, who said she had osteoporosis and ‘Would be in a wheelchair for the rest of her life. Another doctor told her that she was producing too much calcium in her joints and that it would have to beremoved or she would be ae he rest of her life. Ofcourse, this is all her report, but we ca dread and an expectation of returning to that helpless t Freud referred to. One aspect of her arthritis and migraine was that it often occurred when her mother want something from her. Her journals were filled with conflicts over physically not being able to meet her mother’s needs. Krystal also spoke of emotions themselves being ‘trauma screens; hence there is a fear of one's emotions and an impairment of affect « ’ tal 1978, p98). This ex Pe fs ovvbelning and intolerable. After reading this it seemed ‘even more important to point out at every opportunity where Jenny did have control and power. Later in the fall I announced that I would be attending an art therapy conference for a few days. Jenny seemed to be having difficulty with this and ‘with a few other life crises. I decided to interview Mr Mad (to Jenny's great relief) as this was one puppet who was ‘allowed’ to express anger without fear of damage or retribution. Mr Mad was able to explain that when Jenny {gets mad, she might sabotage things she is working on. She doesn’t want to show her anger. Mr Mad focused on how people took advantage of Jenny, how her mother demanded that she shop for her even though her arthritis, , how Sally got a dog and got her to take outa loan and then on top ofall that thought she may be pregnant. Life was too difficult so Jenny was feeling overwhelmed by her feelings, suicidal, Dr Laurie Wilson, professor at New York University, had observed in a fecture on psychoanalysis of the artist that ‘masochism was an attempt to preserve ot restore hope through a display of pathos’ and I was on the Jookout for new ways for Jenny to restore hope. I suggested to Mr Mad that