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Art therapy and AIDS

Merz, Regine

Introduction
I started the project ,HIV Art', art therapy for individuals with HIV and AIDS in the Ruhr area, in 1999. The fact that the project was in great demand from the beginning revealed what many of my patients expressed in words later on: they wish to receive professional support in coping with their disease. An HIV infection affects the entire person in his or her environment. Medical treatment addresses the spreading of the virus in the body and thereby the progression of the illness. Frequently the mental burden involved is neglected. Treatment of an HIV infection should therefore always be interdisciplinary. Art therapy may be a meaningful complement. Successes achieved with the HIV Art project suggest wider applications of art therapy as a meaningful intervention for HIV and AIDS sufferers.

Progression of HIV infection

In 2006 about 39.5 million people worldwide were infected with the HI virus (1*). In the same year, 2.611 persons were infected with the virus in Germany, and the number of HIV positive individuals rose to 56.000 (2*). This trend continued in Germany in the first half of 2007 (3*). Despite intensive research efforts AIDS remains uncurable and presents a challenge because of the continuously growing number of new infections. Living with HIV infection and illness is a tremendous challenge for those affected. In the course of the illness there are frequently situations that may trigger anxiety, helplessness and the feeling of being threatened (4*). At first, the news of a positive test result causes strong stress reactions in most individuals affected. In general it involves radical changes in self-perception and life perspectives. Another critical time is the onset of regular intake of medication, of ART (antiretroviral therapy) or HAART (highly active antiretroviral therapy) (5*). Daily medication brings a first awareness of being ill, particularly if there were no previous symptoms of the HIV infection that may have existed over years. Additional stress may be caused by side effects of ART or HAART and longer hospitalization periods (6*). Patients may fear problems in their professional lives if progressive HIV infection reduces resistance or causes early retirement or disability. Many realize only then to which extent they define themselves through their job. A lipodystrophy syndrome (impaired lipometabolism) is experienced as extremely stressful (7*). The lipodystrophy syndrome associated with HIV is a frequent side effect of ART or HAART. It involves clinical changes in metabolism and also mainly physical changes with possible negative consequences for a patient's life quality and adherence (8*). One reason is the impairment of all-important physical attractivity, another the fact that patients become recognizeable as HIV infected through changes in the face (loss of fat below cheekbones) (9*). Many HIV infected persons fear rejection from their social environment. The idea to lose an important other has particularly negative consequences for mental balance. Another critical situation may be a change in individual medication as part of ART or HAART. Inefficiency of ART or HAART or growing resistance of the HI virus may also raise repressed or previously unknown fears. The degree of reactions is individual and depends on a large number of factors, among others on sex. HIV positive women are often confronted with conditions and problems different from those for (homosexual) men in coping with the infection. On the one hand, homosexual men have extended networks available. On the other, HIV positive women are perceived differently by their social environment compared to positive (homosexual) men. Very often, the situation of HIV positive women is characterized by multiple responsibilities like care of a family, often without a partner, keeping the infection a secret (to protect children from discrimination), and limited or no possibilities of exchange (10*). Such factors frequently result in a withdrawal from the social environment, isolation and high mental stress (11*). The following stressors are induced by HIV:
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news of the positive test result fear of discrimination and social isolation deteriorating health onset of HIV therapy problems in professional life financial worries (e.g. unemployment, disability) All these factors show that HIV infection involves closely related medical, psychosocial and social aspects. The progressive course of the disease offers repeated starting-points for art therapy interventions with the aim to improve mental well-being.

Fundamental aspects of art therapy for HIV and AIDS patients

From the beginning of the epidemic, when positive test results meant death because of the impossibility of cure with medication, art therapy was employed successfully to support patients in coping and in coming to terms with impending death (12*) (13*) (14*). Today art therapy may be employed as a form of crisis intervention immediately after the positive test result is made known. Art therapy is also possible as a long-term intervention to improve quality of life. A cross-over study on quality of life shows that HIV patients report improved quality of life after the onset of ART or HAART, mainly with regard to physical health, pain symptoms, physical performance and resistance (15*). Mental stress, however, appears to show only small changes or no changes at all. Depression still occurs more frequently compared to `normal healthy individuals' and are most marked in patients with more advanced disease (16*). Stress events and negative coping mechanisms like depressive mood changes, hopelessness and fatalistic outlook show an evident relation to the progression of the disease (17*). This is why it may be helpful for affected persons to receive psychosocial support in the form of art therapies. Generally, participants in art therapies are not expected to have artistic skills, because patients in this context are asked to follow their current moods and to experiment. Pictures produced this way represent conscious and subconscious mental processes and states. Subconscious and repressed parts of a patient's personality may be made aware again in therapy. It is often easier for patients to express an emotion spontaneously with paintbrush and paints than with words. This is the first step towards a constructive confrontation with the personal situation. This process provides patients with the opportunity to reflect and alter mental events in the content and form of their pictures, to discover and try out new things (18*). Art therapy is action and resource oriented, this means, patients become active and no longer feel helplessly exposed to their future lives with a conscious or unconscious focus on HIV. Art therapy helps them to discover inner resources and gather strength to accept and endure the disease, but also to discover new sources of life energy and power. Art therapy offers HIV patients an opportunity to express inner processes in a non-verbal form and thus to enter into a dialogue with themselves, with therapists or other members of the group. In this way, the emerging piece of art becomes a helpful medium of communication with oneself and the environment. A very personal development is initiated to express emotions other than those that are rationalized and categorized. The following examples reveal that for some patients the important thing is not to describe their condition but rather to shape it and change it in painting, to build up a relation to their state of being, to work on it and to explore ways to cope or to find release. The need to reflect on the HIV infection and individual coping strategies in a protected context is just as strong as the wish to maintain physical health via medication as long as possible. This wish is most pronounced in long-term infected patients who have been living with the virus for more than 15 years. The probability of HIV specific symptoms and ailments increases with survival time. Even today, HIV infection still affects the entire person, the body and the psyche; treatment plans should therefore involve interdisciplinary cooperation of physicians and therapists.

HIV ART, art therapy for individuals living with HIV and AIDS
Brockmeyer sees art therapy as a meaningful complementary intervention in the treatment of HIV and AIDS patients (19*). In 1999 I initiated the art therapy project HIV ART in cooperation with the group around Brockmeyer. 10 patients from
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the Ruhr area attend art therapy sessions on a regular basis. Their average age is 43, the youngest is 37, the oldest 56. Apart from painting techniques with acrylic paints they learn to perceive themselves and their emotions. What they experience as threatening may lose some of its threat just by being artistically interpreted and viewed with detachment. Acrylic techniques permit overpainting, so that patients see how minor changes may alter the entire impression a picture conveys. Self-experience and competence as experienced in art therapy strengthen self-esteem and confidence in personal ability. This is reflected in the pieces of art which I shall present later as examples. The therapeutic objectives of HIV ART are: psychosocial stabilization positive self-esteem and confidence improved self-competence support in building up new perspectives in life improved quality of life Art therapy offers patients opportunities to handle their anxieties and depressions individually and to decide for themselves what and how to paint. Many HIV infected persons who attend my art therapy sessions say they do not wish to take other medication in addition to HIV medication, and by no means psychotropic drugs. Instead they prefer to do something to further their own well-being. The pictures they produce document personal, individual development.

Case 1
Male patient, homosexual, 37 years, positive HIV test three years ago, category C of CDC classification, psychologist with diploma and a focus on client centred interviews, currently unemployed. He learned of his infection three years ago. Together with the test result came the diagnosis of advanced stage. In the course of regular blood tests and visits to the Bochum university clinic he heard about the art therapy project HIV ART. He has been attending art therapy for one year on a regular basis. After the shock of the test result and the diagnosis he struggeled to regain his inner balance. He wanted to just learn painting, in a group of like-minded persons where he did not have to conceal his infection and the problems involved. After half an hour he was already completely absorbed in the painting process, experimenting intensively, painting over what he had done before, and following new impulses. He became thoroughly involved and forgot to think about his infection. Back home after his first therapy session, he began to reflect on what it was that had happened to him in painting. In the following sessions he used mainly dark colours in memory of a stay at the seaside (see figure 1). Restraint in choosing colour nuances was important to him, and he enjoyed working with dark shades of blue and black exclusively. He produced a picture that evoked the impression of a nightly walk although he never saw the sea at night the way he presented it.
FIGURE 1.

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This picture revealed to him the need to let go of his cognitive side if he wanted to address his emotions. For him, the emotional world is represented by dark colours, the rational mind explains and enlightens this world with the light of cognition. In order to perceive his emotional world, and without the explaining and ordering power of the mind, he advanced tentatively with dark colours. For him and his analytical mind his verbal comments on his pictures were very important and took up almost as much time as the painting process itself. He discovered himself in his pictures; his painted expressions tell him something about his attitude towards life. As a qualified psychologist he is used to helping others; therefore he finds it hard to see himself in the role of the person seeking help. From this perspective it is easier for him to accept the statement expressed in his painting, just as if somebody had told him. With the following paintings he gained some technical experience and achieved a better balance between emotional and rational aspects, his colours became lighter, and landscapes assumed realistic hues (see figure 2).
FIGURE 2.

In his job he used to analyse situations and to focus on problems. In art therapy he learned to look at the entire picture, to perceive changes in the statement made by the picture through minor alterations. He learned more about himself in observation, in trying to keep everything in sight and to achieve decisive change even with small things. It is not always necessary to change your whole life; sometimes small things are enough to cause essential change and to feel all right
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again. He gave another of his pictures a blue shade as background which he liked and which he made darker or lighter in places. The many nuances he mixed with this blue were enough so that he did not need additional colours for his picture. The general impression was again that of a landscape. But only a definition of horizon made him perceive a separation of sky from earth and provided a perspective to the picture.
FIGURE 3.

He knew such situations from personal experience. The decision to draw a line for the horizon provides perspective, in the same way his decisions provide clarity and structure in his life. This was an important insight and an essential stimulus for his return to everyday life with the virus. He opted for outpatient treatment to find a structure for his days, and to take up at least part-time employment. In art therapy he realized that he can live with the HIV infection and is not a helpless victim, that he can do something to feel better. This is very important to him, he kept all his pictures since they document what he did and achieved. Shadows play an important role in his life and his paintings. The existence of shadows is proof that there is light.

Case 2
Female patient, heterosexual, 50 years, tested as HIV positive 18 years ago, category C of CDC classification, retired. She has been attending art therapy over years. At the beginning she was quiet and absorbed in her painting, had almost no contact to others in the group. She understood her paintings as little as she understood her life. Again and again she asked whether her picture was finished, because she could not say. She did not understand her own pictures. But she loved to mix the paints and to observe how new shades and nuances emerged. She preferred warm earth colours for her paintings (see figure 4).
FIGURE 4.

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She needed clearly defined motives in order to recognize a statement in her paintings. She successfully used a still life as a stimulus for an idea of her own, or copied a classical modern work of art, freed herself from the model picture and found individual expression which she was then able to understand.
FIGURE 5.

As soon as this patient found her way in painting, she started being more courageous and less insecure in other areas of life as well. She has established a stable relationship to other group members. Self-competence experienced in art therapy helps her in her daily life. Formerly she was insecure about the dosage of HIV medication and just took fewer pills; today she discusses medication with her physician because she wants to understand. The clarity and statement recognizeable in her paintings today are recognizeable in her life. Art therapy as a long-term intervention has become an important instrument for her to find access to herself and to develop personal coping strategies. She requires a defined structure to achieve order out of chaos, like in painting, and she can employ this structure to make statements or to shape her path in life.
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A side effect of art therapy was to raise her interest in art in general so that she visits art exhibitions of all genres in the Ruhr area in her search for new ideas.

Summary
Despite intensive research efforts, HIV infection still is a complex phenomenon and a challenge to medicine in 2007. The vast progress made in the past decade in developing new drugs helped to improve treatment modalities considerably with antiretroviral therapies or highly active antiretroviral therapies. The infection does no longer automatically lead to a process of deterioration, a return to life is possible under new and better conditions. The disease had changed into a chronic illness with individual progression. Treatment of the infection is as complex and varied as the progression of the disease itself; some factors, like self-determined life, improved life quality, and development of adequate coping strategies, cannot be influenced with medication (20*). Art therapy offers a wide range of opportunities to support HIV patients in coping, as an acute form of intervention and also as long-term therapy. In art therapy patients find ways of individual interpretation and thereby learn something about themselves, discover personal resources and develop new perspectives and a new outlook in life. Many patients demand interdisciplinary treatment plans to take all their individual needs properly into account (21*). The manifold positive effects and high degree of acceptance of this therapy form among HIV patients suggest that a wider application of art therapies are indicated. German health insurers assume the costs for art therapy for breast cancer patients for example. It appears worthwhile to add art therapies for HIV and AIDS patients to the general catalogue of interventions assumed by health insurers in Germany.

References
(1*) UNAIDS, WHO (2006). Die AIDS-Epidemie - Statusbericht Dezember 2006, WHO Library. (2*) Robert Koch Institut (2007). HIV-Infektionen und AIDS-Erkrankungen in Deutschland, Epidemiologisches Bulletin Sonderausgabe A. (3*) Robert Koch Institut (2007). HIV-Infektionen und AIDS-Erkrankungen in Deutschland, Epidemiologisches Bulletin Sonderausgabe B. (4*) Arendt, G., Haslinger, B. A., (2003). Psychiatric diseases and HIV infection. These patients are dually stigmatised, MMW Fortschr Med. (5*) Berg, C. J., Michelson, S. E., Safren, S. A. (2007). Behavioral aspects of HIV care: adherence, depression, substance use, and HIV-transmission behaviors, Infect Dis Clin North Am. (6*) Johnson, M. O., Neilands, T. B., (2007). Coping with HIV treatment side effects: Conceptualization, measurement, and linkages, AIDS AND BEHAVIOR. (7*) Reid, C., Courtney, M., (2007). A randomized clinical trial to evaluate the effect of diet on quality of life and mood of people living with HIV and lipodystrophy, J Assoc Nurses AIDS Care. (8*) Behrens, G. M. N., Schmidt, R. E., (2006). Das Lipodystrophie-Syndrom, HIV.NET 2006. (9*) Paterson, D., L., Swindells, s., Mohr, J. et al. (2000). Adherence to protease inhibitor therapy and outcomes in patients with HIV infection, Ann Intern Med 2000 (10*) Franke, G. H., (1996). Women and AIDS. Results of investigations in the social science, Leipzig: 10. Kongress "Psychologie in der Medizin der Deutschen Gesellschaft fr Medizinische Psychologie. (11*) Liu, C. et al. (2006) Assessing the effect of HAART on change in quality of life among HIV-infected women, AIDS Res Ther. (12*) Fenster, G. M., (1989). Art Therapy with HIV-positive patients: Mourning, restitution, and meaning. Paper and videotape presented at the 20th Annual Conference of the American Art Therapy Association, San Francisco, CA. (13*) Gail, M. E., (1993). Art therapy with HIV-positive patients: Hardiness, creativity and meaning, The Arts in Psychotherapy, Vol. 20.
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(14*) Aldridge, D., (1993). Hope, meaning and the creative arts therapies in the treatment of AIDS, The Arts in Psychotherapy, Vol. 20. (15*) Parsons, T. D., Braaten, A. J., Hall, C. D., Robertson, K. R., (2006). Better quality of life with neuropsychological improvement on HAART, Health Qual Life Outcomes. (16*) Wolf, E., (2002). ,Lebensqualitt im HAART-Zeitalter - Geht es den Patienten wirklich besser?, AIDS und Infektionen in Klinik und Praxis :9. (17*) Arendt, G., (2006). Affective disorders in patients with HIV infection: impact of antiretroviral therapy, CNS Drugs. (18*) Merz, R., (2003). KUNSTTHERAPIE - ber knstlerische Selbsterfahrung positive Effekte zur Steigerung der Lebensqualitt nutzen, Projekt Information 11/4. (19*) Merz, R., Brockmeyer, N., (2005). HIV- ART - an art therapy project, European Journal of Medical Research 10 (Suppl II). (20*) Franke, G. H., Hackbarth, K. P., Potthoff, A., Brockmeyer, N (2005). Aspects of rehabilitation in HIV and AIDS, Hautarzt (21*) Merz, R., (2006). Painting is good for your soul Music Therapy Today VII/4

This article can be cited as:

Merz, R. (2007) Art therapy and AIDS. Music Therapy Today, Vol.VIII (3) December. available at http://musictherapyworld.net

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