A narrative case report of personal recovery from personality disorder through the interventions “An Empowering Story” and art therapy

1.1 An empowering story

An Empowering Story is a narrative psychological intervention through which people with PDs work on their recovery in a personalized way (Pol et al., 2023). With the help of concrete writing assignments, participants write out their life story in a structured manner in the form of a triptych: (1) the past, (2) a key turning point, and (3) the present and future. They read their stories aloud during the sessions and receive feedback. After they have written all stories, they transfer them from the workbook provided into a digital format, accompanied by photos or other visuals. During the final session, they receive a printed book version of their life story.

An Empowering Story is a group intervention designed for 10–12 participants, led by two facilitators. It consists of 12 sessions, each lasting 1.5 h, with 1.5 h of homework each week (Pol et al., 2023). Depending on the target group, the facilitators are trained clinical psychologists, psychotherapists, psychiatrists, nurses, or “experience experts.” The intervention includes a manual for facilitators, a workbook for participants, and a digital platform for creating a “life book.” When there are too few participants to form a group, or when group therapy is unsuitable for a certain client, the intervention can also be offered individually. In the present study, an individual setting was chosen as group therapy was not possible due to the COVID-19 measures.

The intervention was created using a participatory study design (Pol et al., 2023), combining scientific knowledge and methodology with the expertise of mental-health professionals, practical knowledge from biographical coaching, and the lived experience of people with PDs. In a feasibility study (Pol et al., 2023), practitioners and participants evaluated the intervention positively. Participants reported that it had added value compared to existing therapies. They appreciated the clear structure and found that by writing and sharing their stories, they gained a deeper understanding of themselves and developed a more positive outlook (Pol et al., 2023). An effectiveness study with a mixed-methods design showed significant and meaningful effects on personal recovery (Pol et al., in preparation).

1.2 Life-story-focused art therapy

Life-story-focused art therapy is an individual, experiential form of art therapy focused on expressing parts of one's life story through art. Art therapy allows people with PDs and trauma to work on their personal recovery in a person-centered way, using artistic materials and processes. To express their life story, they depict important experiences from their past, present, and future, and discuss the resulting artwork with the therapist. The therapist encourages the participant to explore the materials, develop a personal style, and make individual choices that center their personal experiences. The creative process and the resulting artwork form the basis for self-reflection and meaning-making. Each artwork is saved and can be retrieved at the end of the intervention to provide a visual representation of the entire process. This is discussed and may lead to a final, integrated artwork, or a booklet with photographs of all pieces and/or the art-therapy process. The participant may wish to ritually bid farewell to pieces of art related to certain memories, write a letter (e.g., to their younger self), or burn or bury something (Haeyen, 2018a). The participant is also asked whether they want to take all or some of the pieces home. In all cases, the therapist facilitates a personalized form of integration of the experiences, followed by a wrap-up and conclusion. Art therapy is offered over an agreed number of 1-h sessions in an individual setting.

2.1 Introduction to client and problem description

Hilda is a 68-year-old woman with misophonia, a negative self-image and a recurrent sad mood, interpersonal conflicts and suicidal thoughts. She has been diagnosed with an unspecified PD (301.9) with borderline traits, an unspecified attention-deficit/hyperactivity disorder (314.01 F), and a depressive disorder (recurrent, in remission; 396.350). Hilda is a strong, intelligent, and extroverted woman, verbally gifted and socially adept, experiencing life-stage issues and relationship problems. There are structural, early childhood issues, with a history of physical and verbal abuse and affective neglect which resulted in the perception of not being valued, attachment problems, and emotion regulation problems. Hilda represses her anger but it can also surface explosively. Her difficulties in regulating her emotions may lie at the core of her misophonia, the inability to tolerate the noises made by others.

2.2 Summary of presenting problem

An unspecified PD with borderline traits and early childhood trauma in a high-functioning 68-year-old woman who wishes to work on her personality development to increase her quality of life. She has a desire to live more “for herself” instead of constantly adapting to others. She wants to understand herself better, manage her emotions, and learn to recognize the boundaries between herself and others.

2.3 Description of client's history, background, and life experiences

Hilda grew up in the Netherlands as the eldest child in a family with two parents, a sister (14 months younger) and two brothers (8 and 11 years younger). Her mother was originally engaged to her father's brother, who remained missing after World War II. Hilda's father subsequently courted her mother but returned traumatized after participating in the Dutch police actions in Indonesia. The couple was pressured to marry when Hilda's mother was pregnant with twins. But 3 months later she lost the twins because of an accident, a loss that was never spoken of. Shortly thereafter, Hilda was born. Until the age of 3, she was a “daddy's girl” and an exemplary child; calm, contemplative, and stable. Her father joined the navy, was often away for work, and tensions rose between Hilda and her mother. Hilda was humiliated by her mother and sister. She was assigned difficult chores and tasks, such as bringing her severely bleeding 3-year-old brother to the doctor when she herself was only 11. Hilda's mother tried to raise the children “properly.” At the table they were expected to behave correctly and chew quietly with their mouths closed. Hilda had the sense that she had to fight to be seen, although this did not lead to the validation she desired. From the age of 4, she was systematically verbally abused by her father and physically beaten. Hilda was often covered in bruises. Once, her father squeezed her throat when she was 11. She felt an ever-present threat of violence.

At the age of 16, Hilda left home. A few years later she married a man who had children from a previous marriage. Together, they had a daughter and a son. She and her husband have been married for 40 years. Then they separated although they stayed living next to each other. Her psychological problems had begun early in life in the form of depression and substance use. She reported that taking care of her children and doing her work, leading internal communications in complex organizations, gave meaning to her life again. Later, she quit her job to care for her grandchild. When her daughter went to live independently with her granddaughter, and she was alone again the depression returned.

From a young age, Hilda had difficulty tolerating the noises and movements made by others (misophonia). In her opinion, the misophonia developed because she always had to be self-contained at home; showing emotions was out of the question. It is described that misophonia seems to be sustained by underlying PD or maladaptive interpersonal schemas (Natalini et al., 2020). Hilda indicated that although she seemed strong on the outside, she did not feel that way at all. She experienced mood swings and got “stuck” in certain emotions as she had never learned to express them. She wanted to learn to recognize the boundaries between herself and others. In social situations, she often misinterpreted or missed signals, resulting in conflict. Her apparent combativeness made her vulnerable to counter-reactions from others. Hilda was perceived by the therapists as a resilient, spontaneous, playful, self-deprecating woman with a sense of humor.

2.4 Case formulation

Hilda participated in the psychotherapeutic day-clinic program at a center of expertise for people diagnosed with PDs. The multi-methods approach consisted of cognitive behavioral therapy (schema-focused, compassion-focused, and dialectical behavior therapy); group psychotherapy; art, music, and psychomotor therapy; and social reintegration. After completing this program, Hilda experienced slight improvement in her five personal goals: (1) regain my will to live, (2) process traumatic experiences, (3) clarify my expectations and feelings toward my life partner (the relationship seems to have more downsides than upsides), (4) learn to spend time alone and overcome thoughts of suicide, and (5) learn to deal with negative feelings (the misophonia is sometimes unbearable). She felt the need to reflect more extensively on certain experiences. She wanted to give herself the space to mourn the pain and losses of the past, to make room for new, positive experiences in the present and future. Therefore, Hilda was offered the opportunity to continue her treatment individually with An Empowering Story and life-story-focused art therapy. These parallel interventions allowed her to look back on her life in a structured way. An Empowering Story would invite her to use her writing skills, and art therapy would allow her to express her emotions in a less verbal and more symbolic, affective, and sensory way, connecting with a deeper emotional level. Through the process of writing and creating artwork, she would be prompted to depict and reflect on her experiences.

2.5 Course of treatment

An Empowering Story begins with an introduction with a life (time-)line, followed by a triptych:

Part 2 is written before Part 1 to help clients get in touch with their strength before looking back at the past. The art-therapy intervention was structured around the same triptych, but conducted in chronological order. For the sake of readability, we describe the full course of treatment in chronological order.

2.5.2 Part 1: The past, with a negative and a positive moment

I am a girl from the polder. For generations, hundreds of years, our lives took shape in the clay of Westland, where clouds and water meet on the horizon. Clouds propelled by the strong winds that whipped land and people. But we did not allow ourselves to be blown over; we learned to bend like the reeds that surrounded us. And there was a lot to bend. What life was like for the generations before me, I can only guess. The only constant was the land of wind and water and, of course, the major and minor disasters faced by each generation. It produced fighters, people who stood tall in all weathers. So that's where I come from.

 

But sometimes fate takes things too far, as was the case with my parents. When disaster after disaster befalls you, you have to bend over so long that you can barely stand up. It becomes a state of being, leading to fusion and disfigurement. If not in yourself, then in your offspring. My parents had six children, the eldest two of whom soon called it quits. Wisely, they chose the path of least resistance and went back to where they came from after only a day or two.

 

You may wonder why I became so cynical, and I would like to share something about that. I can tell you about major and minor beatings, major and minor humiliations, but those are [just] facts … Much worse was the contempt, which sucked the life out of you. You wonder how it could have come to this, but I don't know. It creeps in.

 

An Empowering Story

In the introductory exercise, Hilda talked about her first name and what it meant to her. She had been given the name of her sister, one of the deceased twins. She was teased at school about her name and changed it three times. At the age of 18, she returned to her own name, which means warrior. As homework, she began creating her life line in preparation for writing her life book. This gave rise to a great many emotions. The difficult events she hoped to have processed were still affecting her and influencing her life. She felt sad and angry at how her past had shaped her and how much pain it continued to cause. However, she also had positive and pleasant memories. During therapy, she shared a positive and negative moment from her life story. When reading them aloud, she was moved by the negative moment and enthusiastic and energetic about the positive moment.

Art therapy

Hilda was motivated and kept track of everything in a creative journal. Yet she wanted to go beyond this, sharing the process with someone she knew instead of going through it alone. We agreed that the key was the visual lifeline, in which she would reflect on what she had experienced when and how this had shaped her. She mentioned that she had learned to not want anything and had stopped trying to have a plan for herself, since so much in her life had not been allowed. Her life experiences had been crucial in developing this attitude. Ultimately, she bought a piece of canvas and painted it at home. She emailed pictures of her work and during the session we reflected together on what she made.

Hilda found it difficult to get started with the painting. She alternated between working busily and falling silent, feeling guilty and down as a result. She began by writing and making sketches, then made a start on a picture of her parents (Figure 1). Her father appeared to evoke more sympathy in Hilda. He was depicted twice; in one image, holding the two coffins of the twins. Her mother was portrayed as good-looking, but also severe and disapproving. The older brother whom her mother initially intended to marry was depicted as a kind of ghost, resembling The Scream by Edvard Munch.

Hilda felt that she spent “too long” on Part 1. We discussed what she could do to avoid getting stuck on a piece; for example, rolling up the canvas a bit so that part was no longer visible. The feeling of having ruined the piece troubled her greatly. For the next part, we agreed that she would look at photos from her childhood. Previously, she had commented that she was “actually quite a nice child, who probably didn't deserve to be treated so badly.” She portrayed her mother in a wedding dress instead of a dark suit, reporting that if one “had” to get married, in that time one was not permitted to wear white.

It felt like I was playing with a dress-up doll, and I enjoyed experimenting with lace. And afterwards [I had] the feeling of “So, finally you have your white wedding dress.”

 

She also painted a broken heart, with two boxes underneath. They were barely visible, but Hilda said she did not want them to be too prominent. After a few sessions of working on this drawing, she reported that looking at it made her feel sad and cry. She said it was also about “wanting to forgive.” She now permitted herself to make emotional contact with her sadness. At other times, she tended toward harsh self-deprecation and described herself mockingly as “lifelong promising.” She agreed to try to write something positive about herself every day in her journal.

2.5.3 Negative moment

I remember a birthday where I went around to the guests offering something sweet. One of my aunts (who, of course, knew how things went at our house) complimented me on what a nice job I had done. From across the room, my father shouted loud and clear over the heads of all the guests, “That one? That one's not worth beating to death.” It was a phrase he'd used before in reference to this by now scared little thing. But it could have been worse; like that time I was beaten on the lawn. The problem was not that he did it, but that it happened outside. He was furious. He hit me with a stick and shouted so loudly that the whole neighborhood could hear him. But the worst thing was that I had girlfriends in the garden when this happened. As far as I was concerned, it would have been better if he'd just knocked me into the ground. Off with me, under the green earth. He would have done me a great favor. I think I crawled into the house, not so much from pain, but from shame.

 

Art therapy

Hilda painted herself as a little girl in a swamp, alone and lost (Figure 2a,b). When we discussed this part of her painting, she was emotional about the fact that the feeling she had in this period would always stay with her and had shaped her life. She would have liked to make different choices. She indicated that she felt safe in her present relationship, though there was little connection and spark. She also reported that her partner puts her down when in company.

Hilda began thinking that in her painting, she wanted to skip her adolescence. She wanted to break away from a strict religious environment, but had very low self-esteem. She began acting like a “tough hippie” and did not shy away from the associated loose sexual morals. She now felt that she had crossed some of her own boundaries during that time, but also indicated that she had responsibility and made her own choices, unlike in the preceding period. We agreed that she would still try to depict this period and would email when she was ready to meet again. This way, she was able to control the speed and timing of the process.

2.5.5 Part 2: Turning point toward recovery

An empowering story

Hilda initially resisted identifying a turning point in her life toward recovery. We discussed how a turning point can also be a smaller event, such as the decision to register for treatment. Ultimately, she identified two turning points in her life: the moment she was admitted to hospital at the age of 16 and the moment she became active in the women's movement. She also queried whether the word recovery meant complete healing or acceptance of symptoms. She was invited to continue speaking up in this way; after all, it was important for her to be able to identify with the assignments and get something out of them, not simply do them to please the therapist.

After reading out her turning point, Hilda wrote that she felt saddened by the therapist's remark: “You could have committed suicide afterwards.” The comment had confirmed her own sense of cowardice, when in fact the therapist meant that she (consciously or unconsciously) had chosen not to die and instead, as she herself put it, had to learn to live. That she was still facing life was brave, not cowardly. This exchange of views helped her to understand how she tended to speak to herself, and how this affected what she heard. She also realized that it was important for her to be able to rely on the therapist between sessions. Her emotional response often emerged after a session and disappeared before the next session. Without the opportunity for contact between sessions, she felt that she would miss the chance to verify things and learn from them.

Very early on, I used to fall asleep dreaming about dying. There was something heroic about it, something beautiful. I can't remember what I died of, but I can still clearly see the funeral procession. The weather is beautiful, and I'm lying there sweet and peaceful in my open coffin. I thought of death as a solution from a very young age, it felt like an emergency exit. I wanted to use that emergency exit when I was sixteen. Unfortunately, I woke up, in a huge dormitory with coughing, snoring, crying, bickering, and—in particular—crazy women. It was a terrible experience, so bad that I decided, “Never again!” I didn't yet know how to live, but I decided I was going to learn.

 

Art therapy

Hilda showed the continuation of her painting (Figure 3). It depicted a period during which she felt “broken,” but she did enjoy the attention she received and intimacy she engaged in as a young woman. She had painted herself from behind, standing in front of a mirror, the reflection showing a broken doll. She called herself uptight during this time; sexuality was an outlet. The theme of the next period was motherhood. Hilda had extremely low self-esteem and was afraid of making the same mistakes as her parents. She felt like a bad person, and pitied her daughter for having her as a mother. She said she was depressed at the time.

2.5.7 Letter to her younger self

An empowering story

Hilda initially experienced difficulties in writing a letter to her younger self. Personal beliefs from the past prevented her from being kind and gentle with herself. She wanted to write a friendly letter to her younger self, but was not yet ready to do so. She took the time she needed for this process and got in touch when she had finished the letter. As a child, she felt that her strong opinions had made her “difficult” for her parents. Now she saw that this was not a bad thing, nor did it mean she deserved what had happened in the past. A month later, Hilda wrote a very caring letter to her younger self. The therapist read it aloud, and Hilda was touched. The letter revealed the loneliness she had experienced, and sadness stemming from the lack of attention, support, and love. But Hilda also paid tribute to the strength with which she had managed to sustain herself as a young girl and even now as an adult.

Dear girl, how you longed to hear these words. They were never said to you, nor can you remember being nurtured: hugged or kissed. There were few moments of kindness from your mother. Sometimes your father was in a good mood and we would laugh and play, but that stopped when you were in primary school. So sad. I cry when I think of you. Softness, love, nurturing? Totally unknown. It's a miracle you could even go on at all! What a brave girl you were! How could you have been comforted? If I had been there, how could I have protected you? You were so alone, so terribly alone. And when someone was nice to you, you could hardly believe it was meant for you—if you recognized it at all! Your life would not be easy and often you would have preferred to die. Yet you're still here, and you've been here for so long now that you're rapidly approaching a normal death. But all at once, you don't want to die anymore! What the hell? That's not how we do that! At the very last minute, you swap your fear of living for fear of dying? That's not very useful at your age! But that's not the only change. You start looking around and sometimes you see people who have your best interests at heart. And very occasionally, you even believe them. But the most important thing is that I am with you now, and I won't leave you. I can support you, will support you and help you throughout the rest of your journey. I will also teach you that you can just be who you are and that that is good enough.

 

Art therapy

The final part of the painting focused on how Hilda experienced her life in the present. She worked hard to figure out how to portray the self-images in her life line (Figure 4): herself as a little girl, herself as a young woman (the broken doll), and herself today (the woman in the red dress). First she made them relatively large, then smaller and smaller still in an effort to show how these three symbolic representations of herself walk together, form a united front, and take care of one another. The figures in the foreground are not too prominent, but well on their way to the front and depicted with a hopeful glow, like a shining light over the water (Figure 5).

2.5.8 Epilogue

Something has changed, but to be honest, I can't pinpoint exactly what triggered it. I discovered new points of view while writing and painting, but with so many angles I can no longer see clearly where that change started. Now I am literally and figuratively wrapping up my story. I'm done with it, and when the therapy ends, I want to look to the future. Everything was the way it was. I will carry that with me for the rest of my life. But it will no longer be so all-consuming and an obstacle to further growth. I am no longer just surviving. I can feel again, and dare to trust in that a little more, which makes me more purposeful and able to make better choices. Free, as Descartes put it: I feel, therefore I live.

 

An empowering story

As we discussed the meaning of recovery and how to deal with vulnerabilities, Hilda noted that she still has difficulty staying in touch with herself when interacting with others. Her misophonia could be tiresome for herself and others, and she wanted to become more accepting of it. She also wanted to be less strict with herself, more gentle and compassionate. She had discovered that she could be kind to herself in small ways, such as allowing herself to put on socks or a coat when she was cold. In the final session, Hilda said writing down her life story had been confronting, because it confirmed that these things really happened and could not be erased. She had noticed that she wrote in her own unique “voice,” and was pleased that her “special” brain allowed her to view things with humor, which she saw as one of her strengths.

Art therapy

The full painting, on a large canvas of 3.5 × 0.8 m (Figure 6), has a strong, unified composition, revealing—to Hilda as well as to others—the different periods in her life. It serves as a kind of scroll with symbolic representations of her life journey. She explained that she often thought back to the process of creating it and that it had rekindled her enjoyment of painting. She had started working on other, lighter, pieces.

2.6 Outcome and prognosis

Hilda herself concluded that after this combined treatment she feels more stable, that she can deal with conflicts a little better, that she has a more positive self-image, that she can regulate her emotions better, and that she no longer feels suicidal. She has come to realize and accept that she is “damaged.” Her self-care has improved tremendously and has made a start to being allowed to feel more. She realizes that she is not “done” with this yet. It still requires attention and serious consideration.

2.7 Reflections on the process

Hilda was very involved in the therapy process. She was also very critical of her own writing and artwork. The COVID-19 pandemic brought loneliness, but also the time and peace to work without distraction and do the emotional work involved in reconstructing her life story. She reported that the online meetings were no problem for her, and she appreciated being able to work in the peace and quiet of her own home. She emailed the therapist each time she was ready for the next appointment. Setting her own time and pace gave her a sense of autonomy and freed her from the pressure of fixed appointments and deadlines.

3.1 Implications for future applications of therapeutic approach

In this case the combination of An Empowering Story and art therapy offered a personalized approach in which Hilda's strengths enhanced her ability to manage her personal recovery in relation to PD. The basic principle was the need to understand her own life story to construct her narrative identity and make sense of her experience of mental illness. The structure offered by the writing assignments and the artistic process involved in creating the artwork deepened the process of self-reflection and meaning-making, helping Hilda to recognize and integrate traumatic as well as positive and valuable experiences into a reconstructed life story.

This combined method is very well generalizable. Writing or artistic abilities are not necessary, but a willingness to try and explore is. Artwork in any form can show personal content in an authentic, expressive way, which makes it meaningful and a probable useful therapeutic entrance from a less-verbal perspective (Haeyen, 2018b).

3.2 Implications for dealing with this type of client in future

Working with clients diagnosed with PDs, who have traumatic life experiences, may very well profit from this combined approach in which the life story is written and expressed in artwork. This specific approach allows for the decrease of PD symptoms such as emotion dysregulation, conflicts in interpersonal relations, and a negative self-image because the reminiscence of the personal life narratives allows for the integration of traumatic as well as positive memories, enhanced self-compassion, and meaning making.

In the case of Hilda, this concerned an older client. The implication of this case study is that also older people can profit from focusing on their personal life story. The needs of older people with long-term mental illnesses such as PDs have largely been neglected in policy and research (Curran & Collier, 2016). In particular, traumatic early experiences seem to be overlooked and under-treated in aging patients (Cook et al., 2017). Older people form a heterogeneous group, each with their own unique combination of capabilities and needs. In this case, an older client with PD was experiencing emotional exhaustion due to long-term mental health problems, which affected her ability to manage her emotions and social relations and left her feeling that her life had little meaning. She wanted to regain her will to live, overcome trauma, clarify her feelings, and learn how to cope with negative feelings.

Contrary to the pessimism occasionally expressed toward psychotherapy in later life, recent studies show that psychotherapy can have lasting benefits for quality of life in older adults with PDs (Dinnen et al., 2015; Saunders et al., 2021). Longstanding dysfunctional beliefs rooted in childhood trauma can change even in old age. This means it is important to take account of early traumatic memories when considering older people's personality issues in the present (Curran & Collier, 2016). In this case study, the client was committed to actively engaging in the process of reconstructing her life story. The treatment approach facilitated deep self-reflection, ultimately enhancing her self-compassion and resilience. The process brought her a degree of peace of mind, and she reported that she found it meaningful and valuable.

3.3 Limitations

In terms of limitations, pre-post measures of change are unavailable. Also, the client had previously undertaken a long and comprehensive period of specialized therapy before the presented method was applied which could account for a combined positive effect. This case study was written after the end of the therapeutic process; had the study been planned in advance, we would have specified outcome measures. In an effectiveness study on An Empowering Story (Pol et al., in preparation) as a group intervention we measured outcome with the Questionnaire on Personal Recovery (QPR) and the Personality Inventory for DSM-5 (PID-5) in a naturalistic, prospective study, and in a Multiple Baseline Single-Case Experimental Design (MBSCED) study. This design would also be applicable for an N = 1 study as described in this paper.”

3.4 Conclusion

We conclude that narrative psychological intervention and art therapy can serve as complementary psychotherapeutic modalities to enhance personal recovery in people with PDs and longstanding mental health problems stemming from early trauma. To the best of our knowledge, this is the first time these approaches have been combined to enhance personal recovery. The strength of this combination lies in the integration of top-down and bottom-up emotional processing: cognitive regulation using available knowledge, words, and thoughts; and experiential perceptions using images, symbols, and sensory experiences. Art therapy emphasizes the bottom-up regulatory processes, while narrative psychology supports top-down regulatory processes. Our findings suggest that such a multi-pronged, complementary, and integrated approach to psychotherapy can support personal recovery, including in older adults.