David Gussak Ph.D., ATR-BC

Art on Trial

One Drew Over the Cuckoo's Nest

Art therapy in a forensic psychiatric hospital

Posted Sep 30, 2014

Many art therapists find themselves addressing forensic issues without necessarily working within the traditional forensic settings of prisons, jails, and juvenile detention facilities. These art therapists find themselves in, what some would argue to be, a much more ambiguous and dangerous environment, the Forensic Mental Health Hospital—these facilities combine the most challenging characteristics of the prison and psychiatric facility.  

Since graduating with her master’s degree in art therapy in 2007 from the Florida State University, this post's contributing blogger,Sheila Lorenzo de la Peña, has been providing such services at an infamous and intimidating state psychiatric hospital with forensic patients.

Ms. Lorenzo de la Peña is currently working on her doctoral degree in art therapy at FSU and has contributed the chapter “2D Expression is Intrinsic” in Gussak and Rosal’s upcoming Wiley Handbook of Art Therapy (pub. Date: March 2015).

Art therapy in a Forensic Mental Health Hospital [FMHH]

By Sheila Lorenzo de la Peña

 “...the humiliation and intimidation that comes with being in the role of a psychiatric patient...feeling completely vulnerable to strangers and feeling powerless and small.”

Caughey, M. (2011). Making art, exploring madness. Psychiatric Services. 62(2) p.126-127.

In various publications Gussak and others have, through anecdotes and practical descriptions, identified similarities and differences between forensic art therapy (FAT) and art therapy in forensic settings (FS) [see the post "Investigation and Intervention" here]. In the next few paragraphs I will  provide my observations of art therapy in a similar yet distinct setting--the forensic mental health hospital (FMHH).

FMHH/ITP/NGI-Treatment thru Acronyms

The FMHH population consists primarily of adults and juveniles adjudicated as adults who have a chronic mental health need and who are involved with the criminal court system.  Depending on the need, individuals are hospitalized via the court system for evaluation or treatment. All DSM-V diagnoses are served, with an observed high incidence of dual diagnosis and comorbidity with substance abuse. Most individuals are quite ill.

States use varying classifications but they remain similar: individuals coming into the FMHH for evaluation are incompetent to proceed (ITP) and those who have been sentenced but need to remain at the FMHH due to their mental health needs are deemed not guilty by reason of insanity (NGI). Those who are ITP are treated in order for them to return to court and stand trial. Those returning from court as NGI will need further services to maintain stability and establish needs and resources, towards the possibility of community re-integration.  Due to chronic lack of community placements, the latter can sadly, take years.

Art therapy services can be effective at all steps of the process--from evaluation to extended treatment and community re-integration.

FMHH and FS--Similar and Unique

The art therapist may experience similar institutional dynamics in a FMHH as he or she would experience in a FS: facility guidelines, client needs and abilities, and, above all, safety. However, there are some differences. While similar to FS in that the potential for danger is always present, in prison and jails when the inmates are not in session or working, they can be found in their cells and security is ever present. In a FMHH security may not be as pronounced, and they are not always locked up in their wards, requiring more vigilance from staff who walk and work amongst them.

For various reasons, art therapists will often have to work to do more with less.  It is unlikely there is a designated art therapy space, and they find themselves providing services with mixed groups in classrooms, meeting rooms, or even borrowed offices. While some clients may be in treatment involuntarily, many attend to simply get off their units.

The art therapist then must act responsibly as an “ambassador” (see the post: Therapy in Prison: Where Legal, Ethics, and Morals Collide), of the profession and as facilitator of treatment services.

While FMHHs are different than prisons, art therapists would do well to be versed in the nuances of providing services in correctional settings. While the facility will have stringent rules, guidelines, and regulations they will most likely not recognize the particular issues an art therapist may face in this institution.

At a FMHH the danger of a self-inflicted injury, improper use of media, or exploitation of produced artifacts outside the therapy space is ever present. The art therapist must foresee possible ramifications and weigh them in against any therapeutic benefits to the client and facility. As more art therapists find themselves in such agencies, there is a growing need to educate and advocate for the safety of the client and the continuation of such services.

Mixed Progress—A Paradox in 5 Sentences

A few years ago I noticed an ITP [incompetent to proceed] individual whose art stood out; it looked like he was professionally trained. He demonstrated severe psychiatric symptoms, and he did not speak-- not to me or to his peers.  However, I wanted to work with him. When I spoke to his treatment team they were skeptical but allowed me to proceed.  Everything changed when I realized he primarily spoke Spanish.

In our sessions he made art while he talked about his life, family relationships, education, profession, etc -- all in Spanish (while I brushed-up on my own). He improved--he began to communicate with those around him and even reached out to his estranged family. The art also provided a means of connecting.

With all the progress being made he was soon on his way back to court. He did not return.

He’s likely serving the equivalent of a life sentence in prison.

This story came back to me when I began to write this post.  It was one of many crossroads I came upon. I essentially helped someone get better so they could go to a much more restrictive, anti-therapeutic environment. This stayed with me.

An art therapist will find herself providing new ideas and divergent methods, while, dare I say, making mistakes. It becomes a daily struggle to reconcile our ethical and moral guidelines with what the institution is requesting of us. FMHH is a combination of a FS with a day treatment/mental health hospital. Yet, different from both, the setting presents issues particular to its own sub-culture.

Endnote-Self-care is Imperative

It is important, as art therapists, to take care of oneself and to reconcile such internal struggles. One way is to stay connected with the profession, reach out on social media, and stay creatively active. One way I do this is by engaging in response art to mitigate the encounters, trespasses, and losses.

The following piece is my response in working with the individual described above.[1]

Self-care art piece

Self-care art piece

[1] Blogger’s note: This one of many pieces Ms. Lorenzo de la Peña has made in response to her daily experiences. To see more of her work, check out her blog: Symbolic Projections

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