Psychiatric Bulletin (2006) 30: 109-110. doi: 10.1192/pb.30.3.109
© 2006 The Royal College of Psychiatrists
Psychiatric Bulletin (2006) 30: 109-110
© 2006 The Royal College of Psychiatrists
Art therapy: a senior house officer’s perspective
Hannah Nearney, Senior House Officer in Forensic Psychiatry
Norvic Clinic, Norwich, e-mail:
hannah_nearney{at}hotmail.co.uk
Declaration of interest
None.
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Introduction
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Francis Dixon Lodge is a therapeutic community in Leicester with a capacity
for up to 15 residents. The Lodge also runs a day and out-patient service. The
residential programme runs from Monday to Friday (with residents returning
home at weekends), and comprises twice daily community meetings, twice weekly
small group psychotherapy sessions, a once weekly art therapy group and a once
weekly care-planning group. There is also structured time for recreational
activities, housekeeping tasks and involvement in assessment of referrals. In
addition to planned groups, a crisis meeting can be called at any time by any
community member who feels they or another member are struggling in some way.
This involves calling on the community to think about how to manage the
situation, and is the way that therapeutic communities challenge impulsive
behaviours. Individuals may not be at a stage where they feel able to manage
their feelings at the time and are likely to ‘act out’ in
self-destructive ways, but others around them may be able to offer advice and
support. With time, it is hoped that they are able to develop more elastic
impulse control (Campling,
2001).
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Staff and patients
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The staff have a broad range of experience and include nurses, doctors,
psychotherapists, a social worker, an art therapist and both psychology and
nursing students. The client group mainly consists of those labelled as having
‘severe personality disorder’, the majority being best described
as borderline type. Self-harm, somatic complaints, comorbid substance misuse
and eating disorders, and a history of childhood abuse are all common. Clients
are frequently referred with a history of lengthy contact with acute
psychiatric services, often including difficult admissions where self-harm
behaviour has escalated. As a result of such experiences as adults with
healthcare professionals and disturbed relationships in childhood it is hardly
surprising that residents are often mistrustful on admission.
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Art therapy
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As a senior house officer joining the community for a 6-month placement, I
felt very fortunate to have been given the opportunity to experience something
that many of my colleagues do not have exposure to during their training. So
when it was suggested that I could join the art therapy group as a
co-facilitator, I readily accepted, wanting to derive as much experience from
my stay as possible. It was only after accepting that I realised that I had no
understanding of what the group would involve. I naively assumed that it would
be based on residents producing artwork in a manner similar to my previous
experiences at day hospitals, as a form of recreational activity rather than
as a medium for their therapy. I even wondered if I would be expected to join
in and paint as well! Thankfully, prior to joining the group I received
supervision from the team’s art therapist to prepare me for what was
involved.
The term ‘art therapy’ was first used in the 1940s by Adrian
Hill, an artist who worked with people recuperating from tuberculosis. He
found that these sanatorium patients were able to use the artwork not just as
a form of occupation but as a medium through which anxiety and trauma could be
expressed. During the 1950s, art therapy groups usually existed in an informal
open studio format where patients were free to come and go and discuss their
work individually with the therapist. By the late 1960s and 1970s this had
progressed to the development of formal groups with defined boundaries and
greater attention paid to group dynamics. For further information on the
history of art therapy see Waller
(1991). Art therapists today
possess both a degree in art and a Master of Arts or Master of Science degree
in art therapy and are state-registered. It is a mode of therapy highly valued
by users. Karterud & Pedersen
(2004) compared subjective
benefit of a range of therapeutic groups and showed that the art therapy group
received the highest user satisfaction ratings.
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Francis Dixon Lodge
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Art therapy was introduced at Francis Dixon Lodge a few years ago in
response to the staff team’s feeling that it would be beneficial for
residents who were finding it difficult to articulate their feelings. At
times, residents may feel ‘stuck’ in the groups but may be able to
produce an image in art therapy that expresses their feelings. The art therapy
group at Francis Dixon Lodge runs once weekly for 90 min and is attended by
all residents. It is led by a trained art therapist, and co-facilitated by
regular staff members with an interest in the group. The session is divided
into two stages. During the initial stage the residents come together to
create their work in the presence of the facilitators. This is then followed
by a period of discussion, where everyone present is able to view the work
that has been produced, and thoughts and feelings about the work are explored.
Currently at the Lodge the artwork takes place in the dining room and the
group moves into the lounge for the discussion period, but a dedicated art
therapy room is in the process of being set up that will be accessible to both
the staff and residents at all times. However, several residents have
experienced difficulty working in the dining room related to issues around
eating and transference issues relating to memories of family and school.
As with all groups at the Lodge, boundaries of the group are set by the
community. All residents are expected to make a commitment to attend and to
make every effort to remain in the room, even if they have finished their
artwork before the group is scheduled to end. If a resident is struggling to
the degree they feel unable to stay in the room, there is an expectation that
they will inform the group and go to wait in the discussion room for the rest
to join them. This boundary is felt to be particularly important as it
encourages residents to stay with their feelings evoked by the work rather
than distracting themselves with a coffee and a cigarette for example, only to
enter the discussion period unable to access those feelings. Following the
discussion, the art therapist keeps the work in an individual folder for each
resident, thus building up a ‘portfolio’ of their work that they
can access at any time and keep when they leave. This provides them with a
tangible, lasting record of their therapy which is open to later reflection.
The facilitators meet for after-group supervision, when the work and the group
dynamics are discussed further.
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Patients’ perspective
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On joining the group, it quickly became apparent that several of the
residents struggled with the art therapy. A common observation shared by many
was how difficult it was to spend quiet time focusing on themselves, then to
be left with a concrete reminder of their issues in the form of their work.
For some, it would be a major achievement to be able to produce any artwork at
all. At times, the group could become a channel for destructive feelings and
resistance, especially if following a difficult community meeting. The group
could be a place to protest, particularly against the ‘task’ to
produce some work. Boundaries were frequently challenged, on occasion work
would be produced but then promptly destroyed before it had been seen by
others. Some would attempt to either ‘plan’ their work prior to
the session or always produce work in a very similar style, perhaps in an
attempt to avoid the vulnerable feelings that freer expression might bring.
Some residents would refuse to take part at all and others would leave the
group early without letting the group know. If such behaviour occurred it
would be challenged during the discussion group. At other times the group came
together in a cohesive way. I recall one group in particular, where the
community was reeling from some extremely destructive behaviour by a resident
that had resulted in widespread disruption to many community meetings and
conflict among both residents and staff. Expecting the group to be fragmented
and resistive, I entered with a feeling of dread but was pleasantly surprised
to find the majority of the residents were keen to come together and use the
group. Later on, during the discussion that followed, they were able to talk
openly and constructively about the difficulties within the community.
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Author’s perspective
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Much more than the artwork itself is open to exploration or comment during
the discussion group, including body language and choice of materials. I was
struck by how much could be learned about the residents’ states of mind
and relationships within the community simply by sitting back and observing
them working. Some residents used fragile or messy materials, producing work
that required handling with special care after the session lest it would be
damaged or deposit colour on to the surroundings. In these situations it often
felt as if the resident was communicating their need to be looked after and
borne in mind. It was common for some residents to produce images so small
that they were easily overlooked by the group, and this could be likened to
the experience shared by many of feeling insignificant within the community. I
noticed that such individuals were able to increase the size of their work as
their confidence grew. During my time in the group it was also not uncommon
for new issues to be introduced through the artwork long before they could be
spoken about within the community. It seemed to be therapeutic for such images
with important, but as yet undisclosed, meanings to be simply acknowledged by
the group. For example, one resident produced a sinister looking picture of a
monster creeping out of a box. Some weeks later they were able to elaborate
further and begin to talk about envious feelings for which they felt deeply
ashamed.
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Conclusion
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I feel that my placement at Francis Dixon Lodge has been of huge value to
me both professionally and personally, and my experience there was greatly
enhanced by my involvement in the art therapy group. I would thoroughly
recommend this experience to other senior house officers who are offered such
an opportunity in the future.
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References
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CAMPLING, P. (2001) Therapeutic communities.
Advances in Psychiatric Treatment,
7, 365-372.[Free Full Text]KARTERUD, S. & PEDERSEN, G. (2004) Short-term day
hospital treatment for personality disorders: Benefits of the therapeutic
components. Therapeutic Communities,
25, 43-54.
WALLER, D. (1991) Becoming a Profession:
History of Art Therapy in Britain, 1940-82. London:
Routledge.
Top
Introduction
Staff and patients