Reviews: Art, Psychotherapy and Psychosis

edited by Katherine Killick and Joy Schaverien
London and New York: Routledge
1997 ISBN 0 415 13841 8 (hbk) 0 415 13842 6 (pbk)

Reviewed by Christopher Cordess, Professor of Forensic Psychiatry, University of Sheffield

Reprinted from "Inscape", The Journal of the British Association of Arts Therapists, vol 3(2), 1998, pp73-75

I would (probably) not have found time to read this book at all, let alone in its entirety, if I had not been asked to review it - and I would have been much the poorer. I write as a psychiatrist - predominantly now forensic - and psychoanalyst, who has worked in close association with art therapists and other arts therapists, and as an amateur art lover. Recently, I have become examiner on several arts therapies qualifying courses, partly out of interest and partly as an expression of support. I am no expert and my learning curve is steep. This book gave the great pleasure of putting some flesh of knowledge on areas in which I had but the barest of bones. This review should be read from that perspective - of the curious colleague, but nonetheless an outsider.

I found the ordering of the two parts of the book and the chapters within the different parts of the book idiosyncratic, so I read out of order, as fancy took me, settling first with Chapter 8, 'The History of Art Therapy and Psychosis' by Chris Woods. This gave me a rich and clearly written account of three developmental stages of art therapy in Britain, each broadly of 20 years' duration, from the late 1930s up to our current time. I found myself reflecting particularly on two major issues for contemporary practice raised by Woods: first, questions of technique, theoretical underpinning (and training) and the relation of art therapy to other psychotherapies and psychoanalysis; second, the settings in which art therapy is practised, including a divide between increasing community practice on the one hand, and diminishing inpatient settings on the other. Whilst this is an irresistible consequence of changes of practice within the NHS and specifically the Community Care Act (1990), I found myself reflecting that earlier politics of segregation and control are very much alive for a relatively small but increasing number of patients, especially within forensic practice. This is one area where long-term, in-depth, therapeutic relationships within psychiatric settings or prisons continue to be possible and necessary. (See, for example, the report of the Standing Committee on the Arts in Prisons, 1997.) My own concern is to encourage more posts and raise the profile of such work. But this increases the likelihood of interdisciplinary tensions which are so much part of working in total or near total forensic institutions, to an even greater extent than those described by other contributors to this volume of working within the ‘normal' psychiatric establishment.

I felt I knew about those tensions from the point of view of a psychiatrist leading a multidisciplinary team, with all the issues of professional autonomy versus team playing, team supervision and ultimate decision making. It has been my experience that arts therapists make greater claims to autonomy than say, nurses, social workers or even psychologists in such a setting, and this has sometimes been a source of 'anxious attachment'. At its bluntest, the question has been - especially in relation to borderline, psychotic and 'acting out' patients - who offers the necessary supervision to the arts therapist in the team? Is the supervision sufficiently informed and experienced? Do I need to intervene? These are questions of fundamental importance working in settings with psychotic patients, and raise major questions for training in the arts therapies. In their introduction, the editors address some of these issues in their discussion of the best name for the profession: 'art therapy'? 'art psychotherapy'? 'analytic art therapy'? The last is the editors' preferred term for their own work, which clearly has psychoanalytic sophistication that is not, and cannot be, the case for the averagely trained art therapist. I confess to an anxious concern - but one which to a great extent this book addresses, and to some extent allays. The quality of clinical work and the theoretical underpinning is characterised by a rigour and evident capacity for listening to the patient and for free imaginative thought which is impressive.

I shall now comment upon some of the contributions which had particular impact.

Katherine Killick's chapter on 'Unintegration and Containment' in acute psychosis includes a fine example of individual work with a very sick young man suffering from an acute, then chronic, schizophrenic illness over a total of six years. Her emphasis is uponbthe initial necessity for containment' within the art therapy setting and the provision of actual boundaries, eschewing exploration of content and meaning during the acute, clearly non-symbolic stages of the illness. When the patient reaches that degree of integration that allows for 'objective use, in Winnicott's term, then art therapy can begin to provide the functions of creative play. Killick's psychoanalytic art therapy is informed by post-Kleinian conceptualisations, for example, Bick, Bion and Meltzer, which are well summarised but which, I imagine, might prove somewhat impenetrable for the uninitiated reader. There is a rather sad undercurrent to this work insofar as it had its roots in long-term inpatient work in the 'old NHS'. The 'new NHS', more community based, will not, she maintains, foster or allow such work - and Killick herself left the NHS in 1994. This is a recurring theme throughout the book. With the demise of the physical and psychic holding environments of the old psychiatric asylums, art therapists (as all other 'dynamic' therapists) are needing radically to rethink patterns of practice, types of client and the setting which is good enough' for the practice of art therapy with the psychotic client. As mentioned, the 'forensic' world, as it prospers, frequently by default of other provision, provides the exception.

At a time when psychoanalysts - including Kleinian analysts, who provided much of the impetus in the 1950s and 1960s - have largely withdrawn from intensive individual psychoanalytic therapies with schizophrenic patients, it is intriguing that, on the evidence of this volume, art psychotherapists appear to have taken up the mantle frequently using the conceptual tools of some of the pioneer psychoanalysts. In both cases the clinical work is rich and the understanding gained invaluable for informing other treatments and clinical management, but I have yet to be convinced that interpretive work per se is mutative in patients suffering from severe schizophrenic illnesses. Thus, when Fiona Foster, in a brilliant chapter, observes that schizophrenic patients avoid three-dimensional sculptural forms and the 'body-likeness' and 'life-likeness' of wet, sticky and malleable substances like clay and plasticine, which lend themselves 'to be chosen as external objects for projective identification and therefore become objects laden with psychotic anxiety', I feel that she is probably 'right'. What I wanted to know, however, is how this - albeit compelling hypothesis and way of working - fits into the work of the multidisciplinary team and the experience of the patient of her overall treatment. This is lacking in the description and, if it is lacking in practice, raises questions of how the patient perceives such singular therapeutic interaction.

That is not to say that there is not a strong argument - and some hard evidence (e.g. Matarasso, 1997) - for the generally beneficent individual and social impact of participation in the arts. It is the specific art therapy claim and place that needs to be evaluated, especially in this era of 'evidence based practice'. Hypotheses such as that of Foster quoted above need to be more generally tested, and that is a tall order. The arts therapies share with the generic psychodynamic psychotherapies the huge difficulties of finding an appropriate research methodology, especially where there are multiple therapeutic interventions, as in inpatient care, going on at the same time.

The 'psychoses' described in this book refer largely to patients with schizophrenia and a few with paranoid and manic depressive psychoses. It is not, I think, about patients suffering from borderline states - despite the claim on the back cover. To this extent, diagnosis is fundamentally important, although I detect a certain ambivalence to such 'psychiatric' nosology in some of the contributions. The term 'psychosis', whilst in general usage in the psychotherapies, can be a dangerous confounder of conditions characterised by quite distinct psychic structures. Whilst the Kleinian and post-Kleinian concepts, which are made much (good) use of in this volume, are widely applicable, and are, in my view indispensable as models of understanding, it nonetheless remains the case that such theories account inadequately for the enormous range of difference between distinct types of psychotic illness. Differentiation, in my view, is indispensable too, as, for example, in that of a 'conflict' state from a 'deficit' (or 'defect') state. Also Kleinian theory, I believe, falsely conflates accounts of 'psychotic' experience of the severely mentally ill with those quite different 'psychotic' phenomena of normal infant development (see Gallwey, 1996).

John Henzel, in his chapter, makes explicit the ambivalent attitude towards orthodox psychiatry that runs through much of this book. This contribution helped me realise for the first time how the history of art therapy was largely linked with the anti-psychiatry and alternative psychiatry movements, especially during its 'middle period': an influence which clearly lives on. Yet, Henzel, like Killick and others, regrets the passing of the 'once great social experiment of the "old NHS"', with its ideals and passions. It is true that imaginative, innovative therapies are less likely to be encouraged or allowed in the 'real politik' of the health care offered within the market of the new NHS. But, as Henzel describes, 'Institutions for training in art therapy are now in place and the excitement of the early days of innovation has given way to the respectability of statutory recognition and formal trainings.' Henzel's nostalgia has its appeal and he writes well of 'the last two miserable decades of social life in Britain including a retreat to older psychiatric attitudes and a retrenchment to market economy considerations'. I fear, however, that rather than wait for the times to change ('the times are out of joint'!), it is art therapy's urgent challenge - as, professionally, for the rest of us - to adjust to current mores, whilst hoping to shape the structures of the future.

I found Mann's emphasis upon the possible defensive nature and function of much art stimulating and challenging, since - rather uncritically - I had assumed 'art' to be predominantly a creative process. Also, I had assumed that the arts therapies, including art therapy, in some sense thrived upon their capacities to bypass verbal defence - as, indeed, seems to be assumed by other writers here, including Fiona Seth Smith: I think that this still 'feels' right to me, but clearly one must agree with Mann and with Sue Morter (as differently expressed) in her chapter, that defences should not be equated with the verbal and that many primitive defences are essentially pre-verbal in origin and content.

I was similarly engaged by Mann's statements concerning projective identification, of how it 'works' in the painting process, and his reliance upon this concept - as opposed to Schaverien's coining of new terms and conceptualisations specific to the art therapeutic process. Since I believe 'projective identification' to have become a debased term, now extended to explain away too many phenomena, I find myself more sympathetic to Schaverien's own and original terminology. In particular, I found her theoretical and clinical distinctions between transitional (Winnicott), transformational and (her own) transactional objects, and the 'scapegoat transference' stimulating and, I think, important.

Equally, Greenwood's exploration of ego fragility, ego defence and ego maturation, making use of a different psychoanalytic development (that of 'ego psychology'), felt convincing. From a merely personal point of view, I had a nagging recall of a sceptical editor returning a script to me years ago with the question, "'Ego strength' - how would I measure it?"

I was left with the feeling that art therapy needs very much to theorise its subject beyond the limits of the psychoanalytic heritage. As I have indicated, there are several good examples of just that process in this volume, straining against an apparent culture of possibly undue deference. However, given my strictures about training and supervision in art therapy in my opening paragraphs, it will be apparent that I to am subject to ambivalence with regard to art therapy's autonomy as opposed to a necessary embeddedness within conventional structures.

David Maclagan's chapter entitled "Has 'Psychotic Art' Become Extinct?" raises, perhaps inevitably, more questions than there are answers; especially important is whether "there is something about the original forms of psychotic art that does not fit with either psychological or therapeutic pigeon holes", and the limits of therapy's understanding. This short account cannot do full justice to the subject but raises many of the issues which arise, for example, from the classic volume by MacGregor (1989). Is there a paradox, I found myself wondering, in the reluctance of art therapy historically to pathologise art - as described in this chapter - and yet its tradition, represented in this volume, of its application to mentally very sick people?

This is a well-edited volume containing a range of diverse riches. To quote the authors: "It seemed to us that this book was waiting to be written." I recommend it to libraries, but even more for personal acquisition since it is a book to which one will often return.

Is it too much to hope that in a few years' time, along with the practice of other psychodynamic psychotherapies in the treatment and management of psychosis, a book with a title like "Compelling Evidence for the Effective Art Therapy Treatment of Psychosis" will also be waiting to be written?

References