Art, Psychotherapy and Psychosis

Katherine Killick, Joy Schaverien, Katherine Killick, Joy Schaverien

• Publisher: Routledge
• Year: 2013
• Print ISBN: 9780415138413
• eBook ISBN: 9781134773466
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Art, Psychotherapy and Psychosis reveals the unique role of art therapy in the treatment of psychosis. Illustrating their contributions with clinical material and artwork created by clients, experienced practitioners describe their work in a variety of settings. Writing from different theoretical standpoints they reflect the current creative diversity within the profession and its links with psychotherapy, psychoanalysis, analytical psychology and psychiatry.
In part I specific issues involved in working with psychosis are explored. These include discussion of the therapeutic relationship, the process of symbolisation, the nature and meaning of art made by psychotic patients and the interplay between words and pictures. Part II recounts the history of art therapy and psychosis, tracing its origins in art, to its present-day role as a respected treatment in psychiatric, community and therapeutic settings.
Art, Psychotherapy and Psychosis extends the existing theory, develops analytical approaches in art psychotherapy and offers innovative perspectives for students and practitioners on the treatment of borderline states as well as psychosis.

Part I

Art, psychotherapy and psychosis

Chapter 1

Transference and transactional objects in the treatment of psychosis

Joy Schaverien

In this chapter I develop an idea, initially proposed in Desire and the Female Therapist (Schaverien 1995: 215) that, in the treatment of psychosis, the art object mediates as a transactional object. I have argued that the picture, positioned at the apex of a triangle composed of client-picture-therapist, may be unconsciously experienced as a transactional object.¹ In the treatment of anorexia, it mediates in place of the obsession with food and, when acknowledgement of interpersonal relationships is too threatening, it holds the transference (Schaverien 1989, 1994a, 1994b, 1995). There are major differences in the pathologies, and therefore in treatment of psychosis and anorexia, but in both cases the patient experiences difficulties in relating directly with another person. Therefore it is relevant to consider that, when the transference to the therapist is too threatening, a picture offers a neutral and contained area for mediation; it reveals, captures and holds elusive or potentially overwhelming imagery. In considering this I shall identify two distinct ways in which the picture mediates in psychosis – as a fetish and as a talisman, both of which are magically invested transactional objects.

A linked thread relates to a phenomenon which merits closer attention than it has previously received. I have observed frequently that patients who have experienced psychosis, or who are in its midst, write words on their pictures. It seems that consideration of this might reveal some general points about the process of analytical art therapy in the treatment of psychosis. The hypothesis is that, in the juxtaposition of word and image, there is in the first place an attempt to fix experience and communicate with the self, and in the second an attempt to communicate with an Other. This could be understood to be a move towards community through the mediation of a transactional art object.

THE SCAPEGOAT TRANSFERENCE AND PSYCHOSIS

The theory of the scapegoat transference, as a way of understanding the role of the art object within the therapeutic relationship, developed out of my clinical work with patients with diverse mental health problems including psychosis, (Schaverien 1987, 1991).² As it forms the basis for the ideas in this chapter, I shall briefly review this theory. The scapegoat transference is a form of unconscious transference of attributes and states, through which a picture, or three-dimensional art object, may come to embody otherwise intolerable affect. Fragmented and split off elements in the psyche may be unconsciously externalised and embodied in a picture. Like the scapegoat there may then follow an attempt to dispose of these by disposing of the picture. This is initially an unconscious act, lacking a symbolic dimension. Through the passage of time, and therapeutic interventions, including the safe-keeping of the picture, the ‘disposed of affect is reintegrated. This may then be understood as a symbolic enactment and so the art object serves a positive function as a scapegoat. As a concrete object which embodies the transference it may be understood to be a transactional object. The art object embodied in this way may come to be valued as a fetish or a talisman, consciously or unconsciously, holding elements of feeling ‘live’ within the therapeutic relationship (see Schaverien 1991: 144).

The scapegoat transference has particular implications when working with psychotic patients. Because of its delusional nature the transference in psychosis is often considered untenable. This has, in the past, caused many psychoanalysts and psychotherapists to consider it to be impossible to work analytically with psychotic patients. However, the scapegoat transference makes it possible to do so. The picture, as a third element in the area in between client and therapist, offers a means of externalising otherwise inexpressible thoughts and feelings. Killick (1993) has shown how, over time, they may acquire meaning which was initially impenetrable. Thus the art object offers an alternative means of mediating the split-off and fragmented elements of the psychotic personality. Here they may be contained until the artist feels ready to acknowledge and own them. The picture permits magical investment, as well as expression of otherwise intolerable impulses, and these may be viewed and acknowledged without injury to any person. As a vehicle which temporarily holds potent feelings ‘out there’, and so renders them manageable, the scapegoat picture may be understood to be a significant transactional object.

Psychoanalytic theory plays a significant part in the art psychotherapist's understanding of these processes, as I hope to demonstrate. However, I am arguing that there is an element in the patient's relation to the picture which is particular to analytical forms of art psychotherapy and this cannot be fully accounted for by psychoanalytic concepts. It is sometimes argued that the magical investment in artworks, which I describe, is merely a form of projective identification (Klein 1946, Rosenfeld 1965, Ogden 1982, Grotstein 1985). In consideration of this, I turn to Jung whose theories of the collective unconscious and ‘participation mystique’ (Jung 1963a) have often been compared to projective identification. In recent work Jungian analysts and academics have developed this in writing about communication in the area which they variously call: the area ‘in-between’ patient and analyst (Schwartz-Salant 1989), ‘the Mundus Imaginalis’ (Samuels 1989), ‘non-material reality’ (Field 1991), ‘liminal zone’ (Reed 1996). All argue that a term such as ‘projective identification’, which presupposes that people are fundamentally separate, cannot fully account for the experiences of communication in this mediate area in the analytic situation. I would add that nor does it do justice to the complexity of the interaction when an actual picture exists in the area between the patient and the therapist. There are fundamental connections which underlie all human interactions, and it is relevant to note that psychotic patients are very sensitive to such connections. Furthermore, pictures are not transient like the effects of projective identification; they continue to exist in embodied form and this introduces aesthetic factors into the therapeutic interaction.

THE SETTING

The case material I shall draw upon to illustrate this chapter is from a time when I worked as an art psychotherapist, in a 600-bed psychiatric hospital, with clients suffering from long-term and acute psychotic illnesses. The art room was purpose built; it was large and light with a sink in one corner and shelves for storing paper. Paint and clay were readily available and on one wall was a board where pictures were often displayed. Tables were arranged in such a way that they could be moved according to the needs of the individual and the group. Here I offered open and closed art psychotherapy groups as well as individual sessions. I was a member of a multi-disciplinary team which met weekly to discuss admissions and review the progress of current patients. Patients were referred to group or individual art psychotherapy according to their needs.

In the open, studio group, which was the context for the cases to be discussed below, patients would work alone, sometimes talking to each other, but mostly in silence. The art psychotherapist would move around and speak to individuals within the group. For psychotic patients this is helpful as, in this way, they are able to have as much or as little attention as they seem to require on any particular occasion. The focus of the therapeutic relationship is deliberately centred in the artwork. This is where many of the interactions with psychotic patients are held (Schaverien 1994a). This is rather different from the closed art psychotherapy group where more traditional, group analytic boundaries are established. The formal structure of the closed group means that the frame widens to include attention to the boundaries of the setting in addition to the artwork. Psychotic patients were rarely referred to the closed group and never in the early stages of their admission nor during acute phases.

This setting is evidently different from the current practice of treating people as out-patients in the community and in day centres. However, the need to understand the significance of the artwork in the treatment of psychosis transcends any particular therapeutic setting. In consideration of this it is relevant to make the point that my approach was informed by my previous experience of working in a therapeutic community. Here psychotic processes were accepted as a necessary phase in the treatment of diverse psychiatric states.³ This fundamentally influenced my view of psychiatric illness and enabled me to understand psychosis as a meaningful process. This continues to influence my approach in my current analytic practice.

PSYCHOSIS

Models for understanding psychosis are numerous and diverse. In psychiatric diagnosis distinctions are made between the organic psychoses which ‘are due to demonstrable organic disease’ (Rycroft 1968: 132) and the functional psychoses which include schizophrenia and manic depressive illness. In psychoanalysis Freud distinguished psychosis from neurosis and originally considered the psychoses to be unanalysable (Hinshelwood 1989). This was because the transference was unavailable for interpretation; ‘such patients occupied themselves narcissistically with their own thoughts and psychic constructions to the complete neglect of the external world, including the analyst’ (Hinshelwood 1989: 407). Klein, working with children, observed sadism and persecutory elements in their play and this led her to an understanding of psychotic states in adults (Hinshelwood 1989: 407–12).

It is impossible, in this brief space, to do justice to the many theories of psychosis which have evolved since then but I shall acknowledge those which inform my approach to the clinical material which I will discuss later in the chapter. The philosopher Cassirer, Jung and Lacan⁴ are very different theorists who all contribute to my understanding that what is lacking in psychosis is the experience of self as a member of a community. Each, in his own way, advances a view of the move from concrete identification, where there are only signs, through a mediate area towards language and symbolic articulation. Before discussing the use of words in pictures I shall briefly outline my understanding of these theories.

Cassirer (1955a, 1995b, 1957), in his analysis of symbolic form, develops an understanding of the evolution of consciousness in the cultural field. He argues that, ultimately, it is through the experience of the self as a member of a community that the ‘“I” comes to know it-“self”’. Although it was not his intention, I find this a helpful way of understanding psychosis. The mythical form of consciousness, where ‘every manifestation of [the “I”’s] own personal existence and life is linked, as though by invisible magic ties, with the life of the totality around it’ (Cassirer 1955b: 175), evokes the undifferentiated state which, very often, appears to dominate in the experience of the psychotic patient. This is similar to ‘participation mystique’ (Jung 1963a). Cassirer considers that consciousness begins to evolve through the making of artefacts and tools with specific functions. This leads to the investment of magical significance in particular objects which are often associated with rite or cult. Then, as a more symbolic attitude develops, it becomes ritual and religious consciousness. This is a progression from an unconscious state to a conscious, symbolic form of communal act and to language. The meaningful use of language ultimately brings a separate state of consciousness where the ‘“I” comes to grips with the world’ (Cassirer 1955b: 204).

In considering the role played by art objects in the treatment of psychosis, similar processes are observable. It is through actions and symbolic forms, such as art and language, that a sense of self, and of agency, develops. As already stated, I have proposed that pictures in art psychotherapy transform the psychological state in a similar way (Schaverien 1987, 1991). Belonging to a group involves shared rituals and a common language; it is through these that membership of community is confirmed. The psychotic patient suffers because he/she does not experience him/herself as a member of a community. The use of symbolic forms fails and there is no communal understanding. The spoken word cannot be relied upon to mediate. At this point pictures may form a bridge between unmediated experience and the Other. This may be confirmed by words which are written on such pictures often in an attempt to underline meaning (Schaverien 1984).

The origin of Jung's interest in psychosis is described in Memories, Dreams and Reflections (Jung 1963b) where he writes of his early work in psychiatry and his encounter with his own psychological crisis. Jung regarded psychotic states as a potential within the psyche of all human beings and used the thermodynamic principle of entropy to elucidate (Jung 1928). He explains that energy is transformed as the result of differences in intensity set up by the attraction, and drawing together, of opposite elements – extremes of heat and cold, for example. This sets up intense conflict which, if overcome, gives way to an equilibrium – a sense of security and calm which is not easily disturbed – a genuine resolution. However the intensity is so great that it may result in ‘a brokenness that can hardly be healed’ (Jung 1928: 26). This is the fragmentation so characteristic of psychosis.

The patient who has been overwhelmed by psychosis may appear calm, with rather flattened affect – ‘the so-called “dulling effect” of schizophrenia’ (Jung 1928). If the conflict of opposites is pacified prematurely there may be closure – a false resolution – which results in stasis. At this point the vital feeling disappears and in its place ‘the psychic value of certain conscious reactions press to the fore’ and the patient, who was flooded by the unconscious, may compensate with an over-emphasis on consciousness (Jung 1928: 32). The effect of psychosis may be that the defence against a repeat of such intensity results in flatness of affect. What is missing is the ‘transcendent function’ (Jung 1916: 67). This is the bridge between the conscious and unconscious in which dreams, art and myth are central. In the mediating function of the image there is a link between Jung's writing and that of Cassirer.⁵ I find that both contribute to an understanding of the psychotic patient's transference as it is revealed in pictures.

Lacan's writings are derived from Freudian drive theory and so are rather different in origin from Jung's, which are based on instincts and archetypes. This difference was a factor in the split between Jung and Freud. Despite this I continue to find both to be useful in developing a theoretical framework for analytical art psychotherapy (Schaverien 1994a, 1995). Similarly, both are helpful in attempting to understand why psychotic patients write on their pictures and Lacan, in particular, is significant in this regard because he was influenced by the linguist Saussure (Culler 1976).

In Lacan's writings (1955–6: 179), psychosis is characterised by an undifferentiated state which he calls ‘the Real’. The real is the state where the object sought or desired no longer exists and yet there is a continual search. The ‘real’ is located in the gap between the object and the wish; it is not itself, the object of desire, but rather it is the desire. It is in this area that the ‘lack-in being’ of the psychotic state resides. This has been criticised by feminists as it relates to Freudian ‘castration theory’.⁶ However, Ragland-Sullivan (1992) has suggested that Lacan's ‘lack’ may be understood to be a ‘lack-in-being’, common to both sexes (Ragland-Sullivan 1992: 423). The ‘dulled state’ of psychosis, described by Jung, could be understood to be such a ‘lack-in-being’.

The ‘lack’, the state of identification, is outside the Symbolic Order. It cannot be symbolised and so there is no social link. Between the Real and the Symbolic Order, is the Imaginary which is impossible in psychosis. The Imaginary is not imagination in the accepted sense but, ‘the world, the register, the dimension of images, conscious or unconscious, perceived or imagined’ (Sheridan 1977: ix). The Symbolic is community which is associated with ‘the figure of the law’ and the phallic qualities which bring difference (Lacan 1953: 67). These include boundary setting, law giving, and the entry...

Table of contents

• Cover Page
• Half Title page
• Title Page
• Copyright Page
• Contents
• List of illustrations
• Editors
• List of contributors
• Acknowledgements
• Introduction
• Part I Art, psychotherapy and psychosis
• Part II Context and history
• Index