Graphic Representation of Regression

OMEGA, Vol. 25(4) 259-269,1992
Bronx Municipal Hospital Center, New York
This case study examines a body of art work produced by Emma, a geriatric
client admitted to a psychiatric ward for what appeared to be symptoms of
Alzheimer’s disease. On the ward, Emma attended art therapy groups, where
she spontaneously created metaphors of loss. Her art work showed many
similarities to art work produced by cancer patients. After a three-month stay on the psychiatric ward, Emma was diagnosed with cancer of the liver. She was transferred to a medical unit where she died three weeks later. Emma
produced all her art work before she was diagnosed with cancer. This article
presents evidence that Emma unconsciously knew she was dying, and independently worked on issues of her own death through her art work.
Art productions, symbolic expressions, and dreams have often been utilized when
working with the physically ill. Simon notes that drawings can be directly influenced by the need to express unconscious feelings about death [l]. She professes
that unconscious feelings of bereavement press for expression and containment
in patients’ art productions. The cases she presents include bereavement work
with a variety of types of losses. Simon works with the elderly, facilitating
acceptance of personal death as a natural and inevitable part of life. In addition,
she works with patients who have experienced irreparable physical trauma, helping them accept the loss of a healthy, functional body. Lastly, Simon works with
the terminally ill and their families, helping them accept and work through the
stages of premature death.
Achterberg and Lawlis use guided imagery techniques, at times incorporating
an exercise of having patients draw their illnesses [2]. Jung always valued the
symbolic expression of art and dreams when viewing psyche-soma relationships,
0 1992, Baywood Publishing Co., Inc.
doi: 10.2190/B8U4-3UQ4-XYX6-G0JC
260 / MANGO
and at times used these images to diagnose physical illness [3]. Jung also believed
that dying begins before a person’s terminal illness is diagnosed, and often presses
for expression in dream content.
In her paper entitled “Imagery in Dreams of Illness,” Sabini surveyed a variety
of literature [4]. In this survey she examined the inner symbolic connections
evident in dreams with actual physical disorders. Sabini worked with dreams of
participants who had known illnesses and classified her findings into several
categories [4].
Some clinicians have also begun to gather imagery produced specifically by
cancer patients [5]. Siege1 underscores and works with the graphic psychological
representations in dreams, and has his cancer clients make drawings of illness in
the body [6]. Kern-Pilch described the case of a terminally ill cancer patient [7J
She stated that, with the terminally ill, art fosters the healthy productive self rather
than focusing on the defective passive self. Art is an active modality, and thus can
further serve as a contact with others. Kern-Pilch’s style of work helps patients
focus on what Kubler-Ross defines as “maintaining the quality as opposed to
quantity of life” [8, p. 541.
Upon review of the literature, recurring images seem to be present. Sabini
identifies one category as mechanical and inanimate imagery [4]. The car and
house are often symbols of expression, with the house sometimes an image for the
self. Often in life-threatening illness, dreams show the collapse of the house’s
structure. In Bereavement Art [l], Simon presents Jane, and eighty-six year-old
depressed woman who spontaneously worked on two pictures, one of “houses for
sale” and the other of “cottages for sale” two months prior to her death. Perkins
also reported that children diagnosed as terminally ill drew their own diseased
states within the house [9].
Sabini also identifies a vegetative category including trees. Hammer suggests
that truncated trees with tiny branches growing from the stump represent a feeling
that the core self is damaged [lo]. He states that cutoff and broken branches depict
an individuals’ own feelings of being traumatized, and not a complete unit within
themselves. Hammer has also found that dead trees are a frequent response in
withdrawn, schizophrenic, depressed, and neurotic patients who have given up
hope for a comfortable adjustment. Hammer reports that a dead tree’s occurrence
has negative prognostic significance, as do all other signs suggesting feelings
of futility.
In Wheelwright’s book, The Death of a Woman, the dream of a young woman
dying of cancer is. presented 1111. “I was a palm, the middle of three trees. An
earthquake was about to occur that would destroy all life, and I didn’t want to be
killed by the quake” [ll, p. 2691. Wheelwirght suggests that the earthquake here
represented the destruction of the woman’s own life-she thus became the tree,
the enduring symbol of time. Perkins reports on the appearance of birds and eggs
in the art work of the dying [9]. She speculates that eggs seem to symbolize new
life and hope.
Another theme noted by Simon is the appearance of circles in the art work of
cancer patients. She speculates that the circles represent the fatal wounds of death.
Tate also reported that the mandala or circle often appears in the art work of the
dying, and that the mandala “represents the self and a need for wholeness” that
would logically appear in the art of life-threatened individuals [12, p. 1181.
At times, illness is portrayed by ill or suffering animals [4]. Rudloff reported the
case of Michael, a terminal cancer patient, who had his leg amputated [13].
Michael had drawn one image of a bear attacking a helpless seal (identified as
Michael). The seal was partly devoured by the bear, as was Michael by his cancer.
Imagery found in clients with brain atrophy, including Alzheimer’s and Pick’s
diseases shows less distinct representation. These art productions show neurological, not symbolic psychological findings. Crown reported that art work done
by a Pick’s patient, Anne, was highly disorganized and confused [14].
Wald tracked the graphic representations of an Alzheimer’s patient 1151. The
drawings showed a steady decline from the time of diagnosis to the patient’s death
(usually a five-year course). At first, the patient’s imagery showed disorganization, incoherence, and perseveration. With the progression of the Alzheimer’s, the
imagery showed extreme regression, primitivism, and chaos. These bizarre drawings show a decline in moral standards and explicit sexual expression. Can art
work be predictive? Tate states that “symbols of death may appear in drawings
and projective tests before awareness of dying becomes conscious” [12, p. 1181.
She substantiates this statement with the works of Sternberg and Sternberg [16],
Gordon [17], and Greenberg and Blank [18].
First we reviewed the symbolic psychological art works produced by people
with known physical illnesses. Next, we reviewed the neurological imagery,
produced with technical and mechanical difficulties, by clients with brain atrophy.
These findings bear upon the subject case, where the physical illness of cancer had
not been diagnosed at the time when the art works were being produced.
Emma, a seventy-one year-old black female, was hospitalized on a city
psychiatric ward with what appeared to be the early onset of Alzheimer’s disease.
Approximately eight months before her hospitalization, Emma started showing
confusion and a gradual loss of memory. She became unable to care for herself
independently, leaving potentially dangerous appliances such as the stove, turned
on. She also exhibited bizarre behavior during this time. For example, she carried
a box with her wherever she went. The box contained a magazine picture of a man
she claimed was her husband. Before her illness, Emma had been capable and
independent working for twenty-three years as a nurse’s aid.
Emma presented herself as a well-dressed woman, often proudly strolling
through the psychiatric unit with her bag on her arm. At times, however, thinking
she was a staff member and her shift was over, she became enraged and angry and
262 / MANGO
insisted that she be allowed to leave. Emma also frequently booby-trapped her
room; for instance, when the staff were doing rounds, she would rig her door so
that garbage cans connected by a string would tip over when it was opened. As she
used denial as her major defense, this otherwise sweet woman was often difficuIt
to work with.
A CAT scan revealed enlargement of the ventricle system and general atrophy
believed to be consistent with old age or the onset of Alzheimer’s. After three
months on the psychiatric ward jaundice set in, subsequent medical tests revealed
that liver enzyme levels were off, and cancer was detected. Emma was then
discharged to the medical unit where she died three weeks later-of cancer of
the liver.
During Emma’s three-month hospitalization on the psychiatric unit she was
seen in art therapy four times a week. There she worked on drawings of her
own choice. Once a week Emma also participated in a topic art therapy group,
where she was asked to “draw a picture of something funny that happened to
you.” All groups lasted one hour, with a sharing and discussion period at the end
of each group.
Although Emma drew a number of pictures, a few have been selected that most
clearly deal with the losses she was facing. At first the interpretations of Emma’s
art work were in response to her Alzheimer’s disease-the art revealed organic
deterioration as well as emotional reactions to her loss of functioning. The art
work, however, showed other findings that were never entirely explained by the
Alzheimer’s literature. With hindsight, after the diagnosis of cancer, the pictures
were reviewed again. It was strikingly evident that the cancer material had
been there all along. Emma unconsciously knew she was sick with cancer and
expressed it thru imagery, as she worked on and prepared herself for imminent
In one session, Emma spontaneously produced a drawing of a houseand called
it “House for Sale” (Fig. 1). She drew in pencil and later colored the drawing with
red, green, and yellow markers. Emma tried hard to organize the house, which
does look like a house. However, the house is a facade with poorly connected
lines. The roof does not sit squarely on the frame. The door and window are joined
by connecting lines, making them non-functional. Emma put plants and curtains in
her windows, but continues with the curtains by putting them on the door. These
are organic findings consistent with Alzheimer’s disease. The “red” house suggests that this theme is an emotional one for Emma.
The group discussed difficulties with moving away and leaving one’s home
behind. Emma was also questioned about the fact that she now had to move out of
her home, as she had been evaluated as incompetent and unable to independently
care for herself any longer. Emma reflected on concrete losses. Upon review, with
Figure 1. House for Sale.
the knowledge of Emma’s cancer, she seemed to be dealing with both the loss of
her identity and her impending loss of life. It is possible that she was preparing to
move out of her body, represented by home, when death occurred. Emma no
longer had control or ownership of her body, which had been taken over by
In the topic art therapy group, Emma was asked to draw a picture of something
funny that had happened to her. Emma drew her next-to-last picture, and called it
“forget-me-not.” The event was as follows: a man bought a car, parked it, and
went shopping. When he was ready to go home, the man could not find the car so
he had to walk home. In the group discussion, Emma did not rely on her usual
defense of denial, but was able to talk about some of her losses and about how
unsettling and disconcerting it was to become forgetful. We see marked organic
disorganization in the body and car formation, consistent with Alzheimer’s disease. In the picture, the driver appears frightened, with hair on end, teeth gritted,
and barely touching the steering wheel. Emma may be expressing her loss of
control and inability to steer her life any longer. The car, often a symbol of
mobility and independence, is now lost. Inscribed on the car are the words
“forget-me-not,” with her name in parentheses. Emma, again without prior
knowledge of her cancer, may be foreshadowing her serious illness and death, and
giving a message to the world: “Don’t forget me.”
Over the course of her hospitalization, Emma worked on two pictures with
central images of trees. The first shows a stump of a tree, with foliage growing
from the top, and a bird in her nest. Here is an image of growth and life, drawn in
emerald greens and rich browns. The mother bird and her eggs are comfortably
placed in the tree. The image is also one of rebirth. At this early time in treatment,
Emma was connected with possibility and hope. In Emma’s second tree picture,
there is a banana tree stump that shows fragmentation. The leaves are no longer
connected to the tree and the birds are ungrounded, sitting in thin air. The image is
of a tree breaking apart. The colors are light olive-green and burnt sienna, and
appear less alive than the rich colors of the first picture. The tree, as an image of
the self, expresses the breaking down of psychological and physical functions and
abilities. Thus, Emma may now be expressing her own damaged feelings.
In later works where trees are included but not central to the imagery, as in
Figure 2 entitled “Vanishing Species,” we see a tree that is just a stump, with no
growth or green whatsoever. The tree appears to be in a process of death, if it is
not dead already. In a still later drawing, Emma drew a cross-eyed Saw Whet
Owl, supported only by a floating branch. All of her tree pictures were drawn
Figure 2. Vanishing Species.
consecutively, with a few weeks elapsing between each. The tree images show a
progression of fragmentation, consistent with Alzheimer’s research.
Could Emma’s progression of tree images from growth to disintegration to lack
of growtwdeath predict her own internal death process? Her choice of subject
suggests a psychological awareness of cancer. It might be said that these drawings
are the product of organicity. However, since the choice of subject was always
made by the patient, the construction of the drawing is not the only feature of
Returning to the vanishing species picture (Fig. 2), the drawing includes an owl,
a turtle, a pig, and monkeys-all species that are vanishing. One cannot help
comparing these living creatures that will soon be dead with the direct parallel of
Emma’s inevitable demise. As Emma does not have any children to survive her,
her family line will die with her. The owl and turtle are-patterned with circles and
lines suggesting anxiety, neurological activity, and possibly the growth of cells,
which increases as cancer spreads. On the turtle, Emma makes one central circle
into an eye, giving both the turtle’s and the owl’s eyes a protective, hypervigilant
position. (We can reflect on Emma’s booby-trapping her room to protect herself
during the night). This particular drawing is strongly suggestive of the hypothesis
that art work can foreshadow the death of the artist even when the artist is not
aware that she is dying.
In another humorous art therapy drawing, Emma expressed anger at her situation. Here, her anger is externalized to a dog that is attacking her. In this picture,
Emma had just purchased a dozen eggs when she was attacked by a dog and
knocked down. “What a mess, scrambled eggs, me and the dog,” she stated. For
this intelligent woman to suddenly start forgetting things, Emma’s brain must
have felt like scrambled eggs to her. Consistent with Alzheimer’s, Emma could
here be expressing how everything she did resulted in a mess. This time the dog
personifies the illness attacking her. The cancer becomes externalized, is threatening, and can cause her great harm. On a deeper level, the egg is often a symbol of
self, reproduction, and new life. During a life review stage of illness, Emma, who
never had children, is looking sadly down at the broken eggs-possibly the
children she never had. It also appears that the hope she once had, symbolized in
the egg, is now shattered.
One week later, in yet another humor art therapy group, Emma drew Figure 3, a
picture of a large pet duck biting her hand as she fed it. Her response in the picture
was not to feed the duck for a week, hoping that he had learned the moral of the
story: “Don’t bite the hand that feeds you.” Here, the duck personifies the now
larger cancer attacking her and eating her away. Emma’s response was to try and
gain control over the situation by not feeding the duck.
The last picture Emma drew (Fig. 4) shows one of the three little pigs who is lost
and can’t find his way home. Emma wrote dialogue for the pig on the picture. He
says, “Oh hell I wish the fox would come.” Here the pig wishes for death, again
caused by an attacking animal. The pig looks coldly off to the left of the page,
266 / MANGO
Figure 3. Don’t bite the hand that feeds you.
suggesting the past. Emma was giving up hope, seeing no way out; she was lost
and alone with no way home and no way to return to the person she used to be. Sine
adapted to the inevitable and accepted it, and finally welcomed the end. Through
art work, Emma prepared for, accepted, and perhaps transcended death.
Emma will never be forgotten. The drawings she leaves behind are the legacy
she created.
Emma enjoyed art therapy. She often sketched in her free time, fiiding both
pleasure and satisfaction in this mode of expression. Non-verbal right-brain means
of communication, such as drawing, are often a great resource to individuals who
have lost left-brain verbal abilities. Emma had suffered multiple losses of both her
functional and cognitive selves, as well as the loss of her home and her independence. Spontaneously, she created metaphors of loss in the symbols of her
drawn images. Thus, art therapy became a non-invasive exploration of loss.
Emma’s denial was so intense that she could not have approached this material in
any other way. Eventually, loss became something that Emma could identify,
discuss, and internalize. I hypothesize that the only clue to Emma’s cancer the
Figure 4. Emma’s last picture.
staff had was the inconsistency detected in her representational drawing ability.
At times, her images showed clear organic confusion; at other times they were
well organized. This ‘‘swiss cheese” effect, with pockets of health, was inconsistent with the Alzheimer’s literature that suggests a slow and steady decline of
neurological function.
Emma was also a very humorous individual who never lost her humor, again
inconsistent with reports of Alzheimer’s patients. Although this information was
shared with the treatment team, the inconsistencies could not be explained.
In reviewing the case, could Emma’s neurological inconsistencies have been
evidence of, or complications of, a fatal illness? Could the issues of loss that we so
prominently dealt with in art therapy have been Emma’s own unconscious agenda
to ready herself for death?
All these drawings have graphic images found in the art work of the dying.
Taken as a whole, they support the hypothesis that Emma knew unconsciously
that she was dying and expressed this knowledge in her art. Future studies may
investigate the images and symbols of people who know they are dying versus a
sample of people who are not dying, looking for specific images found in dying
268 / MANGO
people. This study could be followed by a study of people who may be dying but
are unaware of it, comparing groups for statistical significance.
Emma was admitted to a psychiatric inpatient unit exhibiting confusion, neurological signs, and the possibility of Alzheimer’s disease. She was a pleasant
person, but often became angry and defensive. Her aggressiveness was a form of
healthy protest: anger in the service of the self, action to ward off internal threats.
The therapeutic relationship was expressed in metaphor and symbolic form.
Thematic analysis of Emma’s art work makes it clear that she was dealing with
issues of loss-initially the loss of her pre-cancer functional self. Emma’s art
work also depicted the process of realization of her impending death Eventually,
the fatal disease she unconsciously expressed required her transfer to the medical
unit. It is clear that Emma independently worked on issues of her own death, even
though she didn’t know she was dying, through the safe vehicle that only art
1. R. M. Simon, Bereavement Art, American Journal of Art Therapy, 20, pp. 135-143,
2. J. Achterberg and G. F. Lawlki, Imagery ofDisease, Instate for Personality and Ability
3. C. G. Jung, Man artdHis Symbols, Dell Publishing Company, Inc., New York, 1974.
4. M. Sabini, Imagery in Dreams of Illness, Qiadrant, 24, pp. 85-104,1981.
5. M. A. Cotton, Creative Art Expression from a Leukemic Child, Art Therapy, 2,
6. B. S. Siegal, Love, Medicine and Miracles, Harper and Row Publishers, Inc., New
7. K. Kern-Pilch, Anne: An Illustrated Case of Art Therapy with a Terminally I11 Patient,
8. E. Kubler-Ross, On Death and Dying, MacMillian Co., New York, 1969.
9. C. Perkins, The Art of Life Threatened Children: A Preliminary Study, in Creativity
and the Art Therapists Identity, R. Shoemaker (ed.), American Art Therapy Association, Baltimore, pp. 9-13,1976-
10. E. Hammer, The Clinical Application of Projective Drawings, CharIes C. Thomas,
Springfield, Illinois, 1958.
11. J. Wheelwright, Death ofa Woman, St. Martin’s Press, New York, p. 269,1981.
12. F. B. Tate, Symbols in the Graphic Art of the Dying, Arts in Psychotherapy, 26,
13. L. Rudloff, Michael: An Illustrated Study of a Young Man with Cancer, American
14. H. Crown, A Shared Journey: Art Therapy in the Treatment of a Woman with Pick’s
Testing, Champaign, Illinois, 1978.
pp. 55-65,1985.
York, 1986.
American Journal ofArt Therapy, 20, pp. 3-11,1980.
pp. 115-120,1989.
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Disease, TheAmerican Journul ofArt Therapy, 28, pp. 45-50,1989.
15. J. Wald, The Graphic Representation of Regression in an Alzheimer’s Disease Patient,
16. F. Stemberg and B. Stemberg, If1 Die and when I Do, Prentice-Hall, Englewood
17. P. Gordon, Dying and Creating: A Search for Meaning, The Society of Analytical
18. N. Greenberg and H. Blank, Dreams of a Dying Patient, British Journul of Medical
Arts in Psychotherapy, 11, pp. 165175,1984.
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Psychology, London, 1978.
PSYC~O~O~, 43, pp. 355362,1970.
Direct reprint requests to:
Christina Mango
11 Turnare St.
Bergenfield, NJ 07621

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