Art Therapy in Private Practice

Theory, Practice and Research in Changing Contexts

James West

• Publisher: Jessica Kingsley Publishers
• Year: 2017
• Print ISBN: 9781785920431
• eBook ISBN: 9781784502973
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

As perspectives on private art therapy practice evolve, this book provides an overview of the range of approaches, clinical settings, ethical issues and professional considerations when working outside of the formal structures of publically-funded services.

An essential guide for art therapy students and experienced practitioners moving into private practice, it considers the impact of a private context on theory, practice and research. The book features contributions from art therapists with extensive experience in both private practice and public services and gives practical advice on potential difficulties, such as managing relationships with fee-paying clients, self-promotion and maintaining boundaries when practising from home.

Part I

CONTEXTS AND COLLABORATION

1

HOW PRIVATE IS PRIVATE PRACTICE?

— JULIA RYDE —

Introduction

‘How Private is Private Practice?’ is a play on the word ‘private’, which I explore in terms of inner and outer realities. How much are we as therapists able to achieve privacy for those we work with, and for ourselves, and what does it mean in terms of a practice which is private, with the connotations of private sector work, money and accountability?

There are both external and internal pressures that affect the therapist and the patient, and their relationship, in all therapeutic practice. In thinking about writing this chapter for a book about art therapy in private practice, I found I wanted to explore the intricate combinations of these pressures, how they interact, and the tensions that they bring which become an essential part of the clinical work. I will travel from concrete realities to the extremes of unconscious activity. In doing so I want to convey how the therapeutic relationship and the art work become part of the aesthetic of practising outside of an institution.

To bring this alive clinically, one particular painting will be the focus for this. It is a painting out of the many paintings that were executed as part of a therapy. It was painted at a time in the therapy when a dog came into my life. As is often the case with images, they can hold a range of emotions. The painting, however, was lost, neither the patient nor I could find it, but it went on having a life in the mind of us both, which meant it became similar to a dream image.

Before I write about the painting, I will set the scene, covering aspects of my practice, and what I offer.

The Setting

I have a consulting room which contains two chairs, a couch, a plan chest with unused white and coloured paper in it, a table and chair, a basket by the table with art materials in it, and a small chest with drawers for pencils, pastels and so on. These are the concrete objects in the room.

The setting, which can also be referred to as the frame, includes the fact that I see someone on a regular basis, at set times each week, and I will give good warning for any changes to what is initially agreed to, and to holiday breaks. At the beginning of each month I give an invoice for the money owed for sessions.

Over the years since I began a private practice in 1996, there have been changes. I have now gone paperless and send my invoices by email, and the bills are paid by bank transfer or sometimes cash but rarely by cheque any more. It is a very different kind of exchange which has its own advantages and disadvantages, uses and abuses.

I have changed consulting rooms once. During the time in my current room I have always had the chairs and couch in the same positions. The furniture has come and gone and been replaced, the walls have changed colour and the room has gradually morphed into how it is now.

Outside of the Consulting Room

There is a hallway and then the front door and then the outside world.

Anyone wanting to use the lavatory will have to venture past an inner door in the hallway and go upstairs to the first floor. I mention this because, again, these are the concrete realities but they take on inner realities once the work starts.

For some there is a curiosity about going deeper into the house, for others a nervousness and feeling of dread that they will bump into someone. And how might that person see them? As someone in need of help and therefore shameful or as a possible rival who might engender hostility?

One particular patient comes to mind who was sensitive to any intrusion into the space around the consulting room from where she tied her bike up outside to when she got into the consulting room, about a ten-metre radius. Bumping into other people coming in or out of the house or hearing anyone going past in the hallway was a disaster for her. She would be furious with me, accusing me of not protecting the space.

Perhaps a similar but totally opposite reaction to the ‘field’ around the consulting room was in the case of a patient constantly wanting to get me out of the boundaried space and do the session outside.

In both cases this could be about wanting to deny that I had other patients and other people in my life.

Going further afield, there is the question of bumping into patients outside of sessions: in a shop, in the park. Do they see you, or have you seen them? If we have seen each other, I always wait to see if they want to acknowledge me before I respond. Then how it is brought back into the sessions is important to think about. Again, is there a wish for some reason to keep it separate from the therapy work, or perhaps an excited sense of having ‘got’ something more of you?

Working in an institution there are regulations: fire regulations, health and safety ones, security. Over the years, I have had experience of working in a psychiatric hospital and a day hospital run as a therapeutic community. In the psychiatric hospital the art therapy department was in the old laundry building in the grounds. The day hospital was in a different part of town and housed in an old maternity centre. The images of cleaning and giving birth are apt as metaphors for therapy. The old laundry room in the hospital stood on its own in the grounds of a large psychiatric institution built in the 1900s. It was an oasis for the patients from the wards. The day hospital, housed in the old maternity centre, was a part of the community in a more integrated way. Where the private practice is located must have some effect on the work: whether it is in an urban setting, a residential area, a clinic, or a house which is or could be a home.

Using the Space, Using the Art Materials

To come back to the consulting room, it is not only what is said or not said; or with the images, what is made or not made. It is the feel of how you are together in the room. What are the little rituals, gestures, dances that you go through from the moment of walking into the room until the time someone has left? How free do they feel to make use of the space, using the couch, the chair, the floor and the art materials?

What I didn’t say before was that my consulting room is carpeted. With my art therapy hat on, I think: how can you do art therapy in a room that is carpeted? What about being able to make objects, to use paint which might splatter or to make a mess? Since training as an art therapist I have trained as a Jungian analyst, and with this hat on, making images in a session could, by some, be seen as acting out or, more benignly, an enactment.

I have come to feel that whatever we offer in therapy, there are limits. What we bring to the table as therapists is defined not only by the tools of the trade but by who we are. When we qualify we go on to develop our skills. There are certain aspects of who I am that aren’t going to change much, but over the years, and rather like my description of my consulting room, the ‘furniture’ has changed and developed. There is an internal equivalent in that I chuck out some ways of doing things and bring in new ways of working and thinking, and at times return to well-worn theories.

I do not offer a studio-type space where the art materials take front stage, but a room with the conventional two chairs and a couch of a psychotherapist. I have some degree of autonomy about how I look after the room but it has to take into account that the patient is safe, and as a practitioner I must make sure I’m insured to cover any accidents or complaints.

How patients use me, the space and the art materials is all part of the picture which is being built up between us.

Some patients make images outside of the session and then bring them to show me. Some of those who make them in the session sit on the chair opposite with a pad of paper on their laps and talk while they draw; some sit on the couch while they work on something; some sit on the floor and work on an image; some sit at the table, which means having their back to me.

The art materials: I provide paint, paper, brushes, water, clay, pastels, pencils, charcoal.

Patients have created sculptures out of paper; used a hole puncher to make images and used the punched-out circles to make images; sat on the couch moulding clay; dribbled ink down a piece of paper, changing direction until it nearly fell off the paper on to themselves and then my carpet, but never did.

How I Came to the Title for This Chapter

When I thought about the word ‘private’, I associated it with the private sector, which is about having a trade and exchange of goods which is not under direct government control. As a practitioner outside of an institution, the financial aspect is a direct exchange between the patient and myself, and I am under the regulations and ethics of my profession that, I hope, become internalised.

I also thought of ‘The Privacy of the Self’, famously captured in the title of Khan’s (1974) book, and wanted to explore what privacy meant for both therapist and patient.

When I first set up in private practice it was against the regulations of the psychotherapy world to advertise. These days there is a mass of competing websites. As Dalley states in ‘Where now? Looking at the future of art therapy’, ‘The Internet has transformed the social world of adolescents and adults by influencing communication, relationship patterns and social support systems’ (Dalley 2014, p.7). She gives fascinating clinical examples of the use and meaning of chat rooms for adolescents, and use of iPads in art therapy sessions as being part of what art therapists are having to deal with and think about today.

There is the question of what a patient can access about you on the internet. Or you about them. I have caught myself googling someone’s relative and then wondered what drove me to this, making me feel rather like a stalker. Why hadn’t I relied on what was brought to a session? The information is there on the internet and it is tempting to use it. What can be accessed on the internet is about external privacy, which also relates to a sense of internal privacy. Of course this is true for therapist and patient wherever you work, but perhaps in private practice the field is less protected by an institution or a team of colleagues.

Privacy has to be respected and it needs to be nurtured. How much does the patient feel intruded on by our questions, attention or even looks? Winnicott (1982 [1963]) had an acute sense of the privacy of the self and understanding of the wish of a person to be both hidden but also to be found. In this quote he offers

a picture of a child establishing a private self that is not communicating, and at the same time wanting to communicate and to be found. It is a sophisticated game of hide-and-seek in which it is a joy to be hidden but disaster not to be found. (p.186)

And how much do patients intrude psychically on the therapist as a way of communicating how they feel? Bion’s (1993 [1967]) understanding of projective identification was as a form of non-verbal communication between a mother and a baby, used in later life in empathy and in therapeutic encounters.

The trust needed to foster respect and to be able to challenge defences when necessary depends, and is inextricably tied up with, the sense of privacy which is built up through containment (Bion 1993 [1970]; Winnicott 1971) and confidentiality (Bollas 2003). There needs to be a space in which the therapist and the patient can feel comfortable and safe so that the work of containing often unbearable feeling can be done.

The Internal Frame

Containment and reverie are concepts which Bion (1993 [1970]) wrote about in terms of mother/baby interactions where through the mother’s reverie she helps her baby digest raw, overwhelming feeling. In a similar way a therapist receives undigested feeling from a patient, which Bion referred to as ‘beta elements’, and uses their ‘alpha function’ to help process the feelings, and feed them back in a more palatable way.

Internally, the therapist has work to do alongside what the patient is doing. A part of this work is holding the frame of what is happening in the sessions so that it is then possible to gauge and see what is significant in the work with the patient (Bleger 1967). This means how a patient will react to breaks and to fees, and also how a patient will use you, your room, the art materials and the surrounding environment.

All therapists will have examples of breaking a boundary in the face of what is demanded in a particular piece of work with someone. Sometimes it can be a mistake and have disastrous effects, but at other times it can be a turning point in the work. The work we do has its risks and wouldn’t have the transformative potential without this.

I think there are times when we step out of our usual ways of working, and it is important to have confidence in the internal frame to do this, always gauging what is needed for each individual patient. Sometimes the way a patient uses the art materials can take them away from engaging in what may be too painful, and therefore is an autistic use rather than expressive use of images, and a defence. At other times the art work becomes the best possible expression of often unspeakable feelings. An embodied art work becomes alive with transferences (Schaverien 1992), reflecting the relationship, and being available for reference and further thinking as the work progresses, the symbols of the work offering up bridges to often unknown feelings.

This brings me to the painting done which had such qualities but was lost. I will think about the significance of it being lost and its relevance to this chapter later on, bu...

Table of contents

• Cover
• Title Page
• Contents
• Foreword by Joan Woddis
• Foreword by Chris Wood
• Introduction
• Part I: Contexts and Collaboration
• Part II: Working with Children, Families and the Child in the Adult
• Part III: Training and Transmission
• Part IV: Governance and Supervision
• Part V: Research
• Appendix 1 . The BAAT Core Skills and Practice Standards in Private Work
• Appendix 2. Moments of Meeting Project ( UKCP PRN) Semi-Structured Post-Therapy Interview for Clients at 40 Weeks or at End of Therapy
• Contributor Biographies
• Subject Index
• Author Index
• Join our mailing list
• Acknowledgements
• Dedication
• Copyright
• Of Related Interest
• Endorsements