Art Therapy for Psychosis

Theory and Practice

Katherine Killick

• Publisher: Routledge
• Year: 2017
• eBook ISBN: 9781317648017
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Art Therapy for Psychosis presents innovative theoretical and clinical approaches to psychosis that have developed in the work of expert clinicians from around the world. It draws on insights that have emerged from decades of clinical practice to explain why and how specialised forms of art therapy constitute a particularly appropriate psychotherapeutic approach to psychosis.

The contributors present a diverse range of current theoretical perspectives on the subject, derived from the fields of neuroscience, phenomenology and cognitive analytic theory, as well as from different schools of psychoanalysis. Collectively, they offer insights into the specific potentials of art therapy as a psychotherapeutic approach to psychosis, and describe some of the specialised approaches developed with individuals and with groups over the past 20 years. Throughout the book, the meaning and relevance of art-making as a medium for holding and containing unbearable, unthinkable and unspeakable experiences within the psychotherapeutic setting becomes apparent. Several of the chapters present detailed illustrated case studies which show how making visual images with an appropriately trained art psychotherapist can be a first step on the path into meaningful relatedness.

This book offers fresh insights into the nature of psychosis, the challenges encountered by clinicians attempting to work psychotherapeutically with people in psychotic states in different settings, and the potentials of art therapy as an effective treatment approach. It will be essential reading for mental health professionals who work with psychosis, including psychiatrists, psychoanalysts, psychotherapists and arts therapists, and those in training.

Full colour versions of the illustrations can be viewed at http://isps.org/index.php/publications/book-series/publication-photos

Please see p. ix of the book for details of how to access them.

1
THE MATRIX OF THE MIND, THE NETWORKS OF THE BRAIN, AND THE PRINCIPLE OF TRANSFORMATION IN ART THERAPY FOR PSYCHOSIS

Johannes Lehtonen

Introduction

Art therapy is historically closely related to the treatment of people suffering from psychosis (Kennard 2009). In this chapter it will be argued that a psychotic state of mind creates the need for psychotherapeutic methods, such as art therapy, that are able to focus on mental imagery in ways that are not experienced as threatening. In this approach, it is implicit that a person in psychosis is overwhelmed by threats and anxieties that deeply disorganise the cohesion of the mind. It will, moreover, be proposed that the capacity to work on ‘scenic mental images’ is a significant aspect of art therapy in its aim to transform anxious, psychotic mental imagery to forms that are psychologically more adaptive and reality-oriented.

Following an increasing need to combine biological findings with clinical and psychosocial aspects in the research of mental illness (Akil et al. 2010; Portin et al. 2010), this chapter studies mental transformations in two parallel frameworks. The principles of neurophysiological functioning of the networks of the brain and the psychological matrix-like organisation of the unconscious layers of the mind will, respectively, be outlined, and a perspective for their integration will be presented. For an introduction to the theme of mental transformation and its relevance to art therapy, the nature of scenic mental images will be presented in a developmental context by describing their early forms in infancy and their organisation into primary awareness of mental functioning.

How to read this chapter

The aim of the chapter is to bring together clinical and neuroscientific views of the development and nature of the unconscious functions that support mental cohesion, and to this end, an approach using multiple dimensions is necessary. The nature of psychosis is understood in terms of loss of mental organisation and the benefits of art therapy are illuminated in the regaining of the lost cohesion. Although several different approaches need to be integrated, it follows that only a tentative picture can be portrayed in this chapter. The multidimensional approach also involves the use of parallels and analogies between developmental, clinical and neuroscientific aspects. This approach should not be confused with the presentation of causal relationships.

Because psychological and neuroscientific knowledge cannot directly be translated from one to the other, the use of modelling is necessary. Here we deal with a general scientific problem about which Hawking and Mlodinow (2010: 46) write: ‘We make models in science, but we also make them in everyday life. Model-dependent realism applies not only to scientific models but also to the conscious and subconscious mental models we all create in order to interpret and understand the everyday world.’

As Hawking and Mlodinow remind us, facts need a frame or model within which their significance is evaluated. There are no absolutely plain facts in science. A helpful frame for the understanding of observations is always necessary. To compare the subject area of this chapter with an example from another topical research area may be illuminating. Complicated computational models are required for making prognoses of long-term climate evolution, and the models created are only approximations that are accompanied with uncertainty, and they are in constant need of revision, testing and retesting. Problems in credulity and differences in opinion are therefore often aroused. This two-layered structure (facts and models/theories) of science is implicit in the nature of scientific research.

The same tentative pattern of a dialogue between observations and theories also applies to the creating of frameworks for the understanding of mind and brain function. As in other fields, proven facts are the corner stones of the science of the mind and the brain. However, without a wider model that allows a perspective to understand the meaning of facts simultaneously at different levels, research cannot make use of the facts. The theories of Freud, or Damasio and Edelman, to be shortly reviewed, are models that have been created to aid understanding of how explanations grow from observations. Even physics, the most precise of the natural sciences, cannot bypass the necessity of modelling to create the corpus of its theories (Hawking and Mlodinow 2010: Chapter 3).

The model-building relevant for this chapter will start with a delineation of early mental development after birth and its significance for the developing organisation of the mind. Next the principles of neural networks will be presented with the aim of describing them as a background for the understanding of mental functions, especially of the capacity for mental transformation that is crucial in maintaining and restoring of mental health.

Thereafter the concept of the ‘mental canvas’ is presented grounded in an assumption of a cohesive principle in the unconscious mind.¹ Towards the end of the chapter, clinical features that characterise psychotic disorganisation are introduced and the capacity of the cohesive function of art and art therapy will be presented.

Neurophysiological maturation and the multimodal sensory world of the infant

The time during the first few weeks and months of extra-uterine life is connected with more profound developmental changes in brain organisation than will be seen at any time later. Brain regions associated with more basic functions such as sensory and motor processes including the limbic and striatal structures mature first, followed by association areas involved in top-down control of behaviour (Chugani 1998; Casey et al. 2005). At birth, the brain of the newborn is functional at the levels of the brain stem, midbrain, diencephalon and the posterior sensory areas of the cortex. The myelination² of the motor cortex and the prefrontal areas starts proceeding at the age of two-to-three months to continue its development until early adulthood. A balance between the development of new synapses and the pruning out of redundant ones (Casey et al. 2005) leads to the consolidation of those neural networks that are functionally important.

After birth, the continuity of life is based on radically different biological conditions compared to the sensory world prevailing in the foetal period. After delivery, the infant is compelled to adapt to the new extra-uterine conditions. Breathing has to be initiated and reflexive sucking established for gaining nutrients from their provider. During the foetal period, the sensory stimuli impinging on the infant, such as taste, smell, auditory signals, movements and thumb sucking, do not yet have vital implications. The placental supply of oxygen and nourishment is automatic and relatively independent of conditions outside the womb.

In contrast to the foetal period, the stimuli that prevail after delivery signal a formation of a fresh, vital bond between the newborn and its caretaker supported by several physiological and neuroendocrine markers (Uvnäs-Moberg 1996; Gordon et al. 2010). The experiential world of the neonatal infant becomes fuelled through all external senses together with the internal proprioceptive and physiological sensations (the ‘coenesthetic dimension’; Spitz 1957). Repeated experience of satisfaction involves all external and internal modalities that allow the infant’s experiential world to acquire its first organised and meaningful forms. They leave traces in the infant, which can also be observed on a neurophysiological plane (Lehtonen et al. 1998; Cheour et al. 2002; Rinaman 2004; Denton et al. 2009).

The emergence of the nascent mind during the first weeks and months of life can be compared with the creation of a multimodal artwork, and consists of parallel sensory modalities that become integrated. In this sense, the organisation of the experiential world is a product of the infant’s primary psychobiological creativity that precedes the more psychological transitional creativity that emerges towards the end of the first year (Winnicott 1951). The building of ‘networks’ between the sensory channels and motor pathways allows the infant to respond to and form an attachment bond with the caretaker (Fonagy 2001).

The soothing imprints gain particular strength in the most intensive forms of repetition, such as in breastfeeding, in which a double sensation is aroused as the infant receives somatosensory stimulation from the perceptions of its own skin and from the one providing the feeding. The stimulation of the skin and mouth become connected with the effort of sucking and the ensuing experience of satiation, which ultimately link with the safety of being alive (e.g. Brenman 2006: 43; Lehtonen et al. 2006; Lappi et al. 2007). The merger between infant and caretaker helps to build a soothing and life-supporting internal image in the infant to which sensations coming from inside the body contribute.

In the embodied satiation that follows adequate care, the infant’s own sensations and the image of the external caretaker cannot be fully separated by the infant as its cognitive capacities are still waiting to mature, as described by Spitz (1959) and Tyson and Tyson (1990). According to Polan and Hofer (1999), the infant-mother dyad develops into a self-organising unit. From the repeated interactions of care the image of the caretaker gradually consolidates into a sensory and procedural memory network (Kandel 2006), the traces of which can be observed with neurophysiological techniques such as, for example, by comparing the infant’s responses to familiar (mother) and unfamiliar female voices (Purhonen et al. 2005).

Secure experiences of the interaction with the caretaker foster in favourable circumstances the development of the sense of continuity of life and an enduring attachment bond (Winnicott 1949; Schore 2003), accompanied by a sense of an embodied core self (Hägglund and Piha 1980; Stern 1985). At the age of around two to three months, the emerging capacity for goal-seeking sensorimotor coordination and social signalling, such as smiling and reciprocal vocalisation, indicate that an internal model of an external object is developing in the infant. This has led some clinical researchers to hypothesize that there is a process of internal primary identification with the caretaker going on (Hoffer 1981; Salonen 1989; Spitz 1957, 1959; Tyson and Tyson 1990).

The role of the gap between the infant and the caretaker

The changes brought about by birth make the infant familiar with hunger and the need for external provision for the first time, with an ensuing awareness of absolute dependence on the caretaker (Winnicott 1963). The baby cannot live on its own from the start, from which it follows that dependence on the caretaker who herself is not dependent on the infant implies a real danger of discontinuity of care after birth, even though this danger is not often realised. This fact tends to be hidden, however, by the normal and variable, more or less successful, procedures of care. Therefore, the point of view of ‘the fear of breakdown’ presented by Winnicott (1974) is important as it explicitly focuses on this always-present, though seldom realised fear. Ogden (2014), in joining with Winnicott, has pointed out that a break of the securing tie remains a real possibility after birth, and a fear of it never disappears completely. Therefore, exclusively pleasure-related conceptions of the effects of early care do not do justice to the fact that the experiential world of the newborn is always imbued with a basic psychobiological uncertainty of survival.

Clinical signs of the fear of breakdown are seen in disturbances of bonding in the infant-caretaker relationship such as avoidant, insecure-preoccupied or disorganised attachment behaviour (Fonagy 2001). Disturbed attachment is also followed by eating and sleeping disturbances, which are readily accompanied with homeostatic dysregulation and increase in stress hormone cortisol levels (Hofer 1987, 2014; Liu et al. 1997; Gerhardt 2004). The most serious consequences from disrupted attachment have been observed in institutionalised children. In spite of adequate physical milieu and care these children live in a lack of secure attachment and emotional contact. Besides affective apathy, they develop an increased disposition to all kinds of diseases, and their mortality rate is high, as found by Spitz (1945) in his study on the hospitalism syndrome.

Although a comparison of early postnatal stages of development with psychosis may appear far-fetched, an understanding of these dangers in infant development can help the clinician to empathise with a person in a psychotic state. In severe mental disturbances, especially in psychosis, poorly differentiated early forms of mental life can be seen as threatening once again to predominate over more organised mental activity (the infantile psychotic self; Volkan 1995). The sense of a collapse, fear of death and irreversible loss of the vitally important connection to the object world—such as in the space ship travelling forever with no return in Harry Martinson’s ‘Aniara’³—are experiences that are familiar to subjects in a psychotic state, and they resonate with very early and primitive forms of anxiety. The verbal expression of such anxieties, which have been described as organismic panic, is difficult, if not impossible (Pao 1977; Rosenfeld 1992; Volkan 1995; Jackson 2009). A plausible link to the background of such experiences in early infantile fears is therefore relevant to understanding the depth and intensity of the threats in psychotic disorganisation that are beyond words.

Neural networks and the matrix of the mind

In what follows is an attempt to put the development of mental images and art, and their transformation, into a context of the theory of neural networks. It is well known that the major sensory and motor functions of the brain connect to cortical association areas (Brodal 2010) and to subcortical brain structures that subsume affect (LeDoux 1996), and that a joint effect of cortical and subcortical structures is needed for the creation of salience to the sensory processes, i.e. to endow perceptions with affective meaning. The neural structures for visual, auditory and somatosensory experience have been accurately mapped already for some time, as well as the motor centres that control movement and speech. The limbic structures relating to emotion and the right parietal cortical area’s role in mental image formation are also well known (Schore 2003; Brodal 2010).

Moreover, the various brain centres’ roles in artistic creation have also been tentatively delineated, as reviewed by Lusebrink (2004). In a recent fMRI (functional magnetic resonance imaging) study by DiDio et al. (2011), it was ...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• List of illustrations
• List of contributors
• Acknowledgements
• Introduction: places for the mind to heal
• 1 The matrix of the mind, the networks of the brain, and the principle of transformation in art therapy for psychosis
• 2 Psychodynamic art therapy for psychoses: progressive mirror drawing and other sensory integration techniques
• 3 Shaping consciousness: phenomenological art therapy with adults in psychotic states
• 4 The structured studio setting: an ontological dimension in art psychotherapy with psychosis using the concept of body image as structuring function
• 5 A Lacanian perspective on art therapy with psychotic patients
• 6 The side-by-side approach in art therapy for psychosis: deflation and empowerment within the therapeutic relationship
• 7 The Three-Headed Girl: the experience of dialogical art therapy viewed from different perspectives
• 8 An exploration of art therapy process with a detainee diagnosed with schizophrenia in a correctional facility with reference to the use of the comic strip
• Index