The Arts Therapies: A Revolution in Healthcare [2 ed.] 9781138651302, 9781138651319, 9781315536989

Table of contents :
Cover
Half Title
Title Page
Copyright Page
Dedication
Contents
PREFACE
PART I Introductions
Chapter 1 An introduction to The Arts Therapies: ten snapshots from the book
PART II The arts therapies: definitions and developments
Chapter 2 Definitions in flux: contexts and aims
Introduction
Arriving at definitions
Settings and contexts: an overview
Different modalities
Chapter 3 What is art therapy?
Definitions
Aims of art therapy
Chapter 4 What is music therapy?
Definitions
Aims of music therapy
Chapter 5 What is dramatherapy?
Definitions
Aims of dramatherapy
Chapter 6 What is dance movement therapy?
Definitions
Aims of dance movement therapy
Chapter 7 Between the arts therapies
Introduction: differences and similarities
How different is different? How similar is similar?
Arts therapies and arts in health
Professional identity
Conclusion: from definition to exploration
PART III Backgrounds, histories and encounters: from the first happening to the shadow of logic
Chapter 8 From the first happening
Introduction: different histories
Focus on Research: music therapy and Nigeria
Interview with Charles O. Aluede
The first happening and Black Mountain College
Theatre Piece No. 1
Conclusion
Chapter 9 'Everything is ripe'
Introduction: many places
Conference of the Society for Music Therapy and Remedial Music, 1960
Transitions
Professions
Interview with Ka Kit Lai, Amber Chan Hiu Wing, Adeline Chan Ling Hin and Fontane Yiu
Conclusion
Chapter 10 Art and science: the rise of the medical model and the shadow of logic
Introduction: opposites attracting?
Kinds of dialogue
Shadow of logic ?
Conclusion: revolution or collusion?
PART IV Agents of transformation: arts, therapy, play
Chapter 11 The arts in the arts therapies
Introduction: arts and therapy
Situating the arts in the arts therapies
Starting out
Therapeutic improvisation
Creation of an arts space
Case examples
Focus on Research: dialogue with new arts languages and cultures
Interview with Nancy C. Choe
Forms for feeling: improvisation and culture
The art form and the triangle
Experience of the client and meaning
Expressive forms of the arts
Does the art form matter?
Conclusion
Chapter 12 The sensuous encounter: the arts therapies and the unconscious
Introduction: the unconscious – definitions and encounters
Analytic perspective
Artists and the unconscious
The dynamic unconscious
How do the arts therapies position the unconscious?
Arts therapies practice and the unconscious
A particular messenger: uncloaking, excavation and the unconscious
Arts process and non-verbal experience
Emotional encounter
Dynamic relationship
Play space and the unconscious
A dictionary of the unconscious?
Focus on Research: art therapy
Interview with Josée Leclerc
Conclusion
Chapter 13 Playing, development and change
Introduction: definitions and theories of play
What is play?
The arts therapies and play
The play space
Playing and playfulness
The play shift
Play and development
Conclusion
Chapter 14 From the triangular relationship to the active witness: core processes in the arts therapies
Introduction
Artistic projection
The triangular relationship
Perspective and distance
Embodiment
Non-verbal experience
Play and the playful space
The participating artist-therapist
Active witnessing
Conclusion
PART V Client–therapist relationship: paradigms, dialogues and discoveries
Chapter 15 Client and arts therapist: dialogues and diversity
Introduction
Cultures and contexts
Client–therapist transaction
Roles of the arts therapist
Therapist and client
Arts therapy relationships: dialogue and discovery
Arts therapists and clients
Dialogue with analytic psychotherapy
Elizabeth: aims of the dance movement therapy
Elizabeth: method and the client–therapist relationship
Case example analysis
A psychoanalytic framework and the arts therapies: critiques and limitations
Dialogue with a developmental approach to therapy
Sophie: method and the client–therapist relationship
Sophie: aims of the music therapy
Case example analysis
Developmental approach and the arts therapies: critiques and limitations
Dialogue with a mindfulness approach to therapy
Focus on Research: the Inhabited Studio
Interview with Debra Kalmanowitz and Rainbow Ho
The Inhabited Studio: method and the client–therapist relationship
Amiin: aims of the therapy
Case example analysis
Mindfulness and the arts therapies: critiques and limitations
Dialogue with different therapeutic paradigms compared
Why the diversity?
An arts therapies approach versus approaches related to other disciplines
Chapter 16 Client and arts therapist: traditions and discoveries
Introduction
Role of the arts therapist: therapist and client, artist and artist together
Traditions, assumptions, discoveries
Focus on Research: dance/movement therapy, resilience and recovery
Interview with David Alan Harris
Focus on Research: long-term music therapy with young adults with severe learning difficulties
Interview with Mercedes Pavlicevic
Conclusion
Chapter 17 Efficacy: what works in the art gallery? What works in the clinic?
Introduction
What works in the art gallery? What works in the clinic?
Approaches, contexts and efficacy
What is looked at and who is looking?
The arts therapies and efficacy: flying with two wings?
The arts therapies: a range of encounters
Ways of working: considering the effects of the arts therapies
Example 1: Client voice and an ecosystemic approach: Focus on Research
Interview with Kim Dunphy and Tessa Hens
Example 2: Art therapy review of pictures
Example 3: Randomised control trial
Example 4: Collaboration between disciplines: Focus on Research
Interview with Daniel Mateos-Moreno and Lidia Atencia-Doña
A 'researching eye'?
Conclusion
Chapter 18 Concluding remarks
BIBLIOGRAPHY
AUTHOR INDEX
SUBJECT INDEX

Citation preview

‘This welcome new edition is a brilliant guide to the different but related disciplines of the art, dance, drama and music therapies. It will be of interest to all who are working in the healing arts, in whatever capacity, as well as those contemplating a future career. The well chosen and fascinating vignettes make this an accessible book at all levels. Phil Jones has a refreshing, inspiring and much needed international perspective. This book has learned scholarship and an exciting sense of openness to collaboration, with a generosity of breadth and belief in the value of interdisciplinary dialogue. In this volume he encompasses the history and development of the separate practices from a global perspective, antecedents, different contexts of practice and embraces recent new developments. Underpinning all his thoughts is the interconnecting play space central to all of the art therapies.’ Caroline Case, author of Imagining Animals: art, psychotherapy and primitive states of mind ‘In this new edition of The Arts Therapies, Phil Jones paints an elegant, multi-colored landscape of the feld. He stretches our understanding through time by reminding us of the many streams in history that have led to the arts therapies, and through space by bringing forward many voices from around the world. He argues for diversity and multiplicity, for movement and development, over linear and culturally limited perspectives. This is not a textbook: it is a symphony, a group mural, a ballet, a theatrical spectacle that illuminates the intersection of the arts and therapy, and inspires us to remain open and curious about our profession.’ David Read Johnson, Ph.D., RDT-BCT, Yale University, New Haven ‘This book is an invitation to discover the diversity of the arts therapies as an ever-evolving practice that has arisen from a confuence of ideas and languages. Jones disrupts singular accounts of history, defnition, and practice and calls attention instead to how the arts therapies respond to different situations and challenges around the world. The new edition contains a focus on research which both reinforces insights and reveals the complex frameworks through which practitioners seek to assert evidence. This book is necessary reading for all health providers as we contend with a growing awareness of the need for multiple and creative approaches to care.’ Nisha Sajnani, Ph.D., Director, Drama Therapy Program, New York University Endorsements for the First Edition (2004): ‘Phil Jones has brought the feld of the arts therapies one of its most comprehensive, thoughtful and valuable textbooks in this exciting volume. The book shines with intelligence, compassion and a capacity for embracing the differences and commonalities between the arts therapies,

the arts and their usefulness in alleviating pain and the development of human potential.’ Petruska Clarkson, co-editor of The Handbook of Psychotherapy ‘This exciting interdisciplinary volume will be of interest to arts therapists, whether new to the subject or experienced practitioners, to artists and performers and all who are interested in the healing role of the arts. This book is a frst – it brings together all the arts therapies in a single volume – vividly revealing each of them in action. Phil Jones boldly links art, dance, drama and music therapies. He demonstrates their interrelatedness and diversity with remarkable vignettes from clinical practice.’ Professor Joy Schaverien, author of Desire and the Female Therapist ‘This book was waiting to be written, and Phil Jones has met the challenge with vigilance and imagination. It is a truly remarkable contribution to the arts therapies and of the arts in therapy. It is one of the most important books of the decade in the feld, inspiring and creatively written. This informative guide provides a broad understanding of ideas and practice of the arts therapies in health. Its strength is the inter-disciplinary nature of the book, promoting a dialogue concerned with the commonalities and the differences in arts therapies . . . It is both deeply informative and thoughtfully comparative in nature.’ Dr Helen Payne, editor of Dance Movement Therapy: Theory and Practice ‘This is that rare thing, a book which can be recommended to professionals and amateurs alike. I have been waiting a long time for something which would do justice to the unity and diversity of the arts therapies as a whole. Phil Jones’ writing is scrupulously researched, comprehensive and unbiased, exploring the “collisions and connections” within a powerful source of healing . . . A rich book.’ Dr Roger Grainger, author of Group Spirituality ‘. . . a single-handed yet comprehensive introduction to the arts therapies. Each therapy is given its own chapter and theoretical links between the disciplines are outlined. Throughout the book there is a wealth of supportive and illuminating case material drawn from many sources . . . a very fne addition for all interested in the developing arts therapies.’ Dr Leslie Bunt, co-editor of The Handbook of Music Therapy

THE ARTs THERAPIEs The separate arts therapies – drama, art, music and dance – are becoming available to increasing numbers of clients as mental health professionals discover their potential to reach and help people. But what are the arts therapies, and what do they offer clients? This fully updated new edition of The Arts Therapies provides, in one volume, a guide to the different disciplines and their current practice and thinking in different parts of the world. Each chapter draws on a variety of perspectives and accounts to develop understandings of the relations between theory, research and practice, offering perspectives on areas such as the client–therapist–art form relationship or on outcomes and efficacy to help articulate and understand what the arts therapies can offer specific client groups. This new edition features ‘Focus on Research’ highlights from music therapy, art therapy, dramatherapy and dance movement therapy, which offer interviews with researchers in China, Africa, south America, Australia, Europe and North America, exploring significant pieces of enquiry undertaken within recent years. This comprehensive overview will be an essential text for students and practitioners of the arts therapies. It is international in scope, fully up-todate with innovations in the field and will be relevant to new practitioners and those looking to deepen their understanding. Phil Jones is Professor of Children’s Rights and Wellbeing and Head of Research Ethics and Governance at UCL Institute of Education. His books on the arts therapies have been translated and published in China, south Korea and Greece. He has given keynotes in many countries including south Africa, Taiwan, the UsA and Canada and at the Triennial World Congress for Psychotherapy, Australia.

THE ARTs THERAPIEs A Revolution in Healthcare sECOND EDITION

Phil Jones

second edition published 2021 by Routledge 2 Park square, Milton Park, Abingdon, Oxon OX14 4RN and by Routledge 52 Vanderbilt Avenue, New York, NY 10017 Routledge is an imprint of the Taylor & Francis Group, an informa business © 2021 Phil Jones The right of Phil Jones to be identified as author of this work has been asserted by him in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. First edition published by Routledge 2004. British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging-in-Publication Data Names: Jones, Phil, 1958– author. Title: The arts therapies : a revolution in healthcare / Phil Jones. Description: 2nd edition. | Milton Park, Abingdon, Oxon ; New York, NY : Routledge, 2020. | Includes bibliographical references and index. Identifiers: LCCN 2020002906 (print) | LCCN 2020002907 (ebook) | IsBN 9781138651302 (hardback) | IsBN 9781138651319 (paperback) | IsBN 9781315536989 (ebook) subjects: LCsH: Arts—Therapeutic use. | Art therapy. | Psychotherapist and patient. Classification: LCC RC489.A72 J66 2020 (print) | LCC RC489.A72 (ebook) | DDC 616.89/1656—dc23 LC record available at https://lccn.loc.gov/2020002906 LC ebook record available at https://lccn.loc.gov/2020002907 IsBN: 978-1-138-65130-2 (hbk) IsBN: 978-1-138-65131-9 (pbk) IsBN: 978-1-315-53698-9 (ebk) Typeset in sabon by Apex CoVantage, LLC

This second edition is dedicated with love to Jonathan Glover

‘But how can you tread that path with thought? How measure the moon from the fish?’ Conference of the Birds, Fard ud-bin Attar, twelfth century ad

Contents

PREFACE

xvii

PART I

Introductions

1

Chapter 1

An introduction to The Arts Therapies: ten snapshots from the book

2

PART II

The arts therapies: defnitions and developments

17

Chapter 2

Definitions in flux: contexts and aims Introduction Arriving at definitions settings and contexts: an overview Different modalities

18 18 19 23 26

Chapter 3

What is art therapy? Definitions Aims of art therapy

28 28 30

Chapter 4

What is music therapy? Definitions Aims of music therapy

39 39 42

Chapter 5

What is dramatherapy? Definitions Aims of dramatherapy

47 47 50

Chapter 6

What is dance movement therapy? Definitions Aims of dance movement therapy

55 55 57

Chapter 7

Between the arts therapies Introduction: differences and similarities How different is different? How similar is similar? Arts therapies and arts in health

59 59 63 65

xi

xii

Contents Professional identity Conclusion: from definition to exploration

67 69

Backgrounds, histories and encounters: from the frst happening to the shadow of logic

71

Chapter 8

From the first happening Introduction: different histories Focus on Research: music therapy and Nigeria Interview with Charles O. Aluede The first happening and Black Mountain College Theatre Piece No. 1 Conclusion

72 72 77 77 83 85 87

Chapter 9

‘Everything is ripe’ Introduction: many places Conference of the society for Music Therapy and Remedial Music, 1960 Transitions Professions Interview with Ka Kit Lai, Amber Chan Hiu Wing, Adeline Chan Ling Hin and Fontane Yiu Conclusion

89 89

PART III

Chapter 10

91 96 100 104 106

Art and science: the rise of the medical model and the shadow of logic Introduction: opposites attracting? Kinds of dialogue shadow of logic? Conclusion: revolution or collusion?

108 108 109 115 117

PART IV

Agents of transformation: arts, therapy, play

119

Chapter 11

The arts in the arts therapies Introduction: arts and therapy situating the arts in the arts therapies starting out Therapeutic improvisation Creation of an arts space Case examples Focus on Research: dialogue with new arts languages and cultures Interview with Nancy C. Choe Forms for feeling: improvisation and culture The art form and the triangle Experience of the client and meaning Expressive forms of the arts Does the art form matter? Conclusion

120 120 121 124 127 129 133 137 137 139 141 146 150 155 156

Contents Chapter 12

The sensuous encounter: the arts therapies and the unconscious Introduction: the unconscious – definitions and encounters Analytic perspective Artists and the unconscious The dynamic unconscious How do the arts therapies position the unconscious? Arts therapies practice and the unconscious A particular messenger: uncloaking, excavation and the unconscious Arts process and non-verbal experience Emotional encounter Dynamic relationship Play space and the unconscious A dictionary of the unconscious? Focus on Research: art therapy Interview with Josée Leclerc Conclusion

xiii

158 158 161 164 170 171 172 172 174 177 180 181 183 188 188 191

Chapter 13

Playing, development and change Introduction: definitions and theories of play What is play? The arts therapies and play The play space Playing and playfulness The play shift Play and development Conclusion

194 194 196 200 204 207 208 212 213

Chapter 14

From the triangular relationship to the active witness: core processes in the arts therapies Introduction Artistic projection The triangular relationship Perspective and distance Embodiment Non-verbal experience Play and the playful space The participating artist-therapist Active witnessing Conclusion

215 215 216 219 221 223 226 228 229 230 235

Client–therapist relationship: paradigms, dialogues and discoveries

239

Client and arts therapist: dialogues and diversity Introduction Cultures and contexts

240 240 242

PART V Chapter 15

xiv

Contents Client–therapist transaction Roles of the arts therapist Therapist and client Arts therapy relationships: dialogue and discovery Arts therapists and clients Dialogue with analytic psychotherapy Elizabeth: aims of the dance movement therapy Elizabeth: method and the client–therapist relationship Case example analysis A psychoanalytic framework and the arts therapies: critiques and limitations Dialogue with a developmental approach to therapy Sophie: method and the client–therapist relationship Sophie: aims of the music therapy Case example analysis Developmental approach and the arts therapies: critiques and limitations Dialogue with a mindfulness approach to therapy Focus on Research: the Inhabited studio Interview with Debra Kalmanowitz and Rainbow Ho The Inhabited Studio: method and the client–therapist relationship Amiin: aims of the therapy Case example analysis Mindfulness and the arts therapies: critiques and limitations Dialogue with different therapeutic paradigms compared Why the diversity? An arts therapies approach versus approaches related to other disciplines

Chapter 16

Client and arts therapist: traditions and discoveries Introduction Role of the arts therapist: therapist and client, artist and artist together Traditions, assumptions, discoveries Focus on Research: dance/movement therapy, resilience and recovery Interview with David Alan Harris

244 247 247 250 250 250 250 251 252 254 255 255 255 258 259 260 261 261 261 262 264 265 266 267 268 270 270 270 274 277 277

Contents Focus on Research: long-term music therapy with young adults with severe learning difficulties Interview with Mercedes Pavlicevic Conclusion Chapter 17

Chapter 18

Efficacy: what works in the art gallery? What works in the clinic? Introduction What works in the art gallery? What works in the clinic? Approaches, contexts and efficacy What is looked at and who is looking? The arts therapies and efficacy: flying with two wings? The arts therapies: a range of encounters Ways of working: considering the effects of the arts therapies Example 1: Client voice and an ecosystemic approach: Focus on Research Interview with Kim Dunphy and Tessa Hens Example 2: Art therapy review of pictures Example 3: Randomised control trial Example 4: Collaboration between disciplines: Focus on Research Interview with Daniel Mateos-Moreno and Lidia Atencia-Doña A ‘researching eye’? Conclusion Concluding remarks

BIBLIOGRAPHY AUTHOR INDEX sUBJECT INDEX

xv

285 285 290 292 292 297 300 304 306 308 309 309 309 316 320 323 323 328 329 331 335 361 365

Preface

This book attempts to draw together strands of work and ideas developed over many years by many individuals and groups. The primary focus is on those who have been involved in the arts therapies as clients or as therapists. However, others who contribute to our understanding of the development and current state of the feld are included: from surrealists in Europe in the 1920s to musicians in Africa. My aim is to provide a broad introduction to ideas and work, whilst providing specifc insights into particular moments in the therapy room from all the arts therapies. I’ve drawn on published accounts and research along with interviews of arts therapists at work, from Taiwan to Nigeria, from Australia to south America. It is a text that can be looked into for specifc topics and that intends, as a whole, to be a frst book for fnding out about the arts therapies. In addition, though, it is intended for those already involved in one of the arts therapies. For them I hope it can open up the connections between their particular discipline and the other arts therapies – to see both connection and difference and to become familiar with recent innovations and fndings in research. since the frst publication of this book many developments have occurred in the arts therapies. This new edition engages with the fourishing in many different countries of theory, research and practice in a manner that looks to affrm the individuality of the varied contexts, alongside creating dialogue between them. Finishing this manuscript in the Jao Tsung-I Academy in Hong Kong, whilst a guest of Kunst EXA, seems a fitting setting for the subject matter of this book. It is a building that has seen many different identities, and has been inhabited as a sanatorium, then becoming the Lai Chi Kok Hospital for psychiatric patients. As the Jao Tsung-I Academy it now features rooms to stay, a theatre and exhibition spaces, with an echoing presence of both hospital past life and the contemporary presence of the arts and of the changing political, social and cultural forces marking shifts that mirror those that this book engages with. The first edition of The Arts Therapies was one of the first attempts to develop an interdisciplinary overview, with attention to the communities of arts therapists’ work in terms of practice, theory xvii

xviii Preface and history. This edition contains these areas, augmented by recent scholarship, but a key new element recognises the enormous growth of research within the arts therapies. This is a marker of the subject’s maturing identity, and its presence within university systems and health contexts where research is undertaken. The range of research startles in its innovation, its breadth of attention and its different approaches to rigour. These vary from research into the rich arts processes within the arts therapies to the engagement with the more health-situated enquiry of randomised control trials and Cochrane review, from the work of in-depth case studies that parallel research approaches in other disciplines to innovative methods which have not been attempted before and which are unique to the arts therapies. The key to this book is dialogue and meaning making. As with the first edition, it aims to be an accessible text, interested and fascinated by discovery and attempting to tell the tales of the ways the arts therapies have emerged and to create a route through its developments and discoveries. I have tried to bring my experiences and ideas into contact with others – so, though this book is the work of one person, it has drawn inspiration and accounts from many people. I hope that it can now, in turn, be read by practitioners who will develop this work into further enquiry concerning the relationships between the arts therapies. I hope, also, that this book will encourage the investigation of the questions that are at its heart: what are the arts therapies, do they have anything new to offer, and how best can we gain a sense of the ways that they are effective? Professor Phil Jones Jao Tsung-I Academy Kowloon, Hong Kong

PART I

IntroductIons

As in Ecchoes by reflection . . . where we know the thing we see is in one place; the appearance in another. And though at some certain distance the real, the very object seems invested with the very fancy it begets in us; yet still the object is one thing, the image or fancy is another. t. Hobbes in Leviathan (1651: 86)

one

An introduction to The Arts Therapies: ten snapshots from the book this chapter introduces the territory covered by The Arts Therapies, and looks at the main topics and themes within each of the different parts of the book.

Introduction to Part II Chapters 2 to 7 From one perspective, the arts therapies are a continuation, a development of ideas and ways of working which have had different forms and manifestations over centuries. Looked at in another way, though, the arts therapies have emerged in many parts of the world as a contemporary innovation in the way the arts and healthcare can be seen and experienced. this book will analyse that emergence and will provide insight into the ways it is occurring in a variety of contexts. there are different kinds of histories concerning connections between the arts and health. this book provides insight into ways of engaging with the past and present: from arguments that assert the arts are part of ancient traditions of healing which are still extant, to others which review how the arts therapies have emerged as distinct, coherent disciplines and professions within living memory. In a number of countries, art, music, drama and dance movement therapy (dMt) have become recognised as formal disciplines and professions within existing health and care provision.

SNAPSHOT FROM CHAPTER 2 Definitions in time and place A defnition in the arts therapies shouldn’t be something set in stone, that is immovable. the arts therapies naturally need to evolve and change. As disciplines in the early years of their establishment within contemporary health services, we are still discovering much about what they can do and how, or why, they are effective. so, any defnitions

2



  An introduction to The Arts Therapies

3

must be still in process – they are developing maps that show where the disciplines have been, where they are now, and where the arts therapies are going. that is why the following sections answer the question: ‘What are the arts therapies?’ by taking defnitions and asking what they show us about different contexts, ways of working and developments, rather than simply reporting what they say.

the past century has witnessed a massive shift from a situation where there were very few arts therapists, with no professional identity, specific theory or established ways of practising, to one where there is a contemporary flourishing of practice, training, published research and theory with developing recognition by state medical providers in a number of countries. one of the very first academic, professional trainings, for example, was established in music therapy, at the university of Kansas, usA, in 1946. the national Association of Music therapy in the united states followed in 1950. By the end of the twentieth century there were almost seventy degree courses approved by the national Association and its partner organisation the American Association of Music therapy (Bunt, 1997: 250). By the second decade of the twenty-first century there were over 3,940 members of the Association involved in music therapy in the usA, working with over a quarter of a million clients (AMtA, 2017) and conferences, such as that held in seoul, south Korea, bringing in music therapists and delegates from 46 countries (dimitriadis, 2011). this is an example of the advance of the arts therapies from their comparatively recent beginnings. Part II, ‘the arts therapies: definitions and developments’, describes the different arts therapies and their aims. It looks at organisations and associations that oversee training and practice in many parts of the world, referring to arts therapists from the usA to taiwan, from south Africa to the uK. chapter 2 gives an overview of the process of definition, and each subsequent chapter deals with one of the main modalities: art; music; drama; and dance movement. specific definitions of each discipline are given in chapters 3 to 6, though examples of how the arts therapies are practised are also contained throughout the text. this book focuses on art, music, drama and dance movement therapy, as they are the main professional frameworks which have emerged. other areas such as the expressive arts therapies, where all art forms are brought together, are referred to, however.

SNAPSHOT FROM CHAPTER 7 The Lima Declaration, Peru In the ‘frst international Latin American arts and health forum’ which took place in Peru . . . partners developed a ‘visionary statement’

4

Introductions  

entitled The Lima Declaration on Arts as a Bridge to Health and Social Development (Pan-American Health organisation, 2009: 1). Parkinson and White describe it as embracing the ‘whole Latin American continent’ and as fuelled by a ‘vision of the arts as a powerful force for social change, addressing health and economic inequalities’ (2013: 183). they also cite work in Finland as an exemplar of arts and health work with a vision of how ‘health and well-being can be promoted by means of art and culture’: arguing that art and culture ‘can enhance inclusion at the individual, community and societal levels; and everybody should have the right to participate in, and enjoy, the cultural life of the community’ (2013: 185).

the commonalities and differences between art, music, drama and dance movement therapies are described and looked at in terms of what they can offer to clients. Whilst chapters 3 to 6 describe each discipline, chapter 7 looks at the relationship between the different arts therapies, as well as that between the arts therapies and the arts-in-health movement.

Introduction to Part III Chapters 8 to 10 Part III offers insights into different understandings and accounts of how the relationships between arts and therapy has developed.

SNAPSHOT FROM CHAPTER 8 Different histories: interview with Aluede JonEs:

. . . How do you see the relationships between the different histories – the usA tradition and the nigerian? What are the positive elements of this relationship and what are the challenges for music therapists? ALuEdE: . . . the history of music therapy in America is relatively recent compared to that of Africa: in terms of nature, scope and competence, it is currently slim. Important, too, is the fact that the current practice of music therapy is restricted in general hospitals, schools, prisons, health centres, training institutions, psychiatric facilities, private practices and universities, whereas it is boundless in Africa. obviously, there is a general consensus that music is therapeutic. And that people across different climes have musical



  An introduction to The Arts Therapies

5

practices geared towards healing. Beyond healing, music has been acclaimed to have many more attributes. For example, Levitin (2010: 50–1) claims that in Africa, music is not an art form as much as it is a means of communication. singing together releases oxytocin, a neurochemical now known to be involved in establishing bonds of trust between people.

In chapter 8 Aluede offers an account of the development and presence of the interconnections between healing and music in nigeria, and the work of Li introduces practices in shaanxi province, china, such as Yin Kang shi dancing, described by Lü in 239 Bc, where it was a ‘method’ to stimulate blood circulation and enhance immunity. An influential strand of the way history is understood, the emergence of the arts as therapy in Europe and north America, is also encountered in this chapter: through analysis of developments in art, theatre, dance and music at the end of the nineteenth century and early years of the twentieth century. these movements are widespread and vary enormously. they include the surrealists, the revolt in theatre in the soviet union and Germany, from diaghilev’s and nijinsky’s productions such as the Rite of Spring through to developments in jazz. Part III, ‘Backgrounds, histories and encounters: from the first happening to the shadow of logic’, describes and analyses initiatives from this period. It focuses on two specific examples, as a way of sampling many other similar occurrences. chapter 8 looks at Black Mountain college in the usA, a place of experimentation and interdisciplinary discovery. chapter 9 looks at one of the early meetings between those involved in the arts therapies, on 30 April 1960 in London. the movements and experiments referred to above resulted in particular ways of viewing creativity, the imagination, the roles of the artist and of the art form. these arts movements examined areas of expression and experience which had hitherto been seen to be outside the range of what was considered ‘suitable’ for artistic attention. Lyotard presents this as the central tenet of modern representation: ‘to make visible that there is something which can be conceived and which can neither be seen nor made visible’ (Lyotard, 1983: 16). the movements often included an interest in artistic products of people with mental health problems, for example, and the use of techniques devised to free the imagination and to increase spontaneity. the first performance in 1896 of Albert Jarry’s play Ubu Roi is an example of such work, reflecting these concerns in its conception and realisation. It was met by an audience uproar – almost bringing the production to a halt. the audience was in such a state of disruption that violence nearly erupted (Innes, 1993). riotous arguments in the audience almost drowned out the players. this performance has been described as a seminal moment in modern culture, a formative influence on the twentieth-century avant-garde. What was so disturbing? What caused people to revolt? A key to this lies

6

Introductions  

in both the content and form of the performance. the plays in this cycle can be seen to be in line with Jarry’s ‘Pataphysics’, which he defined as a system devoted to unreason, ‘a science of imaginary solutions’ (Jarry, cited in Innes, 1993: 26). on a theatre stage in Paris he was trying to break down the relationship between everyday perception and hallucination: You will see doors open onto snow-covered plains under blue skies, mantelpieces with clocks on them swinging open to turn into doorways, and palm trees flourishing at the foot of beds so that little elephants perching on book shelves can graze on them. (Jarry, 1965: 77) this concern was echoed within other experimental art forms of the time. these involved attempts to reach beyond surface reality, to explore through the arts what was thought of as ‘inner’ nature: dreams, the subliminal, the unconscious. the stage or gallery becomes a place for dreams to become concrete, for the mind to reveal previously hidden thoughts and experiences, for the concerns of the unconscious, rather than the rational, to be played out. taylor could have been referring to Jarry’s work when he draws parallels between the avant-garde in twentieth-century art and the kind of work produced in the arts therapies, ‘during this period avant garde artists became able to do through the activity of painting what therapists today do with their patients – namely explore aspects of feeling that are often not accessible by other means’ (taylor, 1998: 21). As this book will demonstrate, the arts therapies are much more than such a process of exploration. However, taylor’s reference indicates one of the connections that created the context for the arts therapies to emerge: that of the fascination of the experimental arts with emerging ideas of the unconscious and extreme states of mind. As we will see later in this book, the work of groups such as the surrealists, or the experiments at places such as Black Mountain college, described in chapter 8, ‘the first happening’, were all part of this upheaval or experimentation. such challenging of boundaries between different disciplines, such as psychology and the arts, would enable the arts therapies to emerge. Arts therapist Mcniff has said that surrealism may be the clearest link between the arts and arts therapy: ‘during the surrealist era many of the values that currently guide art as medicine began to take shape’ (Mcniff, 1992: 44). the development of arts practices with children in schools and the emergence of arts work from behind asylum walls in many continents, from Asia to Europe, Africa to south America, have also been credited with helping to challenge and widen the notion of what can be described as the ‘arts’. chapter 9 traces examples from art in the Hospital do Juqueri, in são Paulo, Brazil, to omi Gakuen in Japan. Arts practice had occurred within healing contexts for centuries. In the twentieth century, interest and concern with such areas of the arts developed and increased dramatically in many countries. one of the most well-known examples of this concerns the



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initiative begun by Prinzhorn, a doctor in the Heidelberg Psychiatric clinic, who collected art work made by patients in asylums and published them in Bilnerei der Geisteskranken (Prinzhorn, 1922). He believed that these pictures could be viewed as a new art form, previously neither acknowledged nor valued. As we will see, this opening of the asylum doors fed into growing concerns in the experimental arts through movements such as Art Brut and the surrealists. However, the growing interest in the area was not only influential within artistic circles: over the next decades, it helped raise awareness of the ways in which arts products could assist in understanding, communicating with and, eventually, working therapeutically with patients and their conditions. For example, at the international meeting of psychiatrists in Barcelona in 1958, a section on psychiatric art raised such interest that an International society of Art and Psychopathology was established the next year in Paris (Pickford, in o’Hare, 1981: 279). Within the next two decades the flowing tide of interest had resulted in a surge of activity and the unprecedented rise of new organisations, ways of working, professions, training and benefits for users of health services. the International society is only one example of the many initiatives that were beginning to link the arts and therapy. In chapter 9, I will look closely at the ripples from such changes and innovation: from the speeches and ideas of people coming together for a conference of the society of Music therapy and remedial Music in London in 1960 through to interviews with pioneers in contemporary Hong Kong.

SNAPSHOT FROM CHAPTER 9 Arts therapists in Hong Kong cHAn LInG HIn:

the situation twenty years ago involved people from Hong Kong returning here after training in the arts therapies overseas, mainly in the uK and usA. In the beginning it was hard, because the different settings and providers didn’t understand the arts therapies: for example, what the difference was between art, music or drama. now the awareness is improving: this is the effect of even more people coming back to Hong Kong after training abroad and, also, of courses in the expressive arts being developed here in Hong Kong. so people are becoming more aware: ‘oh there is another choice’, when considering therapy. I trained in the usA and have been here in Hong Kong for over ten years. I have consistently worked with funders who provide continuity – for example the cancer Fund, and nGos that fund my practice in different contexts, such as dramatherapy with people with mental health problems in centres and hospitals. YIu: I’m quite new to the feld. some of my work is connected to a response to the increasing rate of pupil suicide in local schools.

8

Introductions  

the Hong Kong Government is starting to pay more attention to the mental health of pupils and providing more funding in this area: they hire more therapists in schools. I work with educational psychologists. In Hong Kong they have more status and bargaining power and the schools are clearer about what work they are doing, they can refer children to me: so I am doing this in partnership. In the future, I would still like to see such partnership, but also I am gathering more details of pupil and parent reactions to the expressive arts therapies and this can help educate settings such as schools about what we can offer.

In such ways, Part III gives a sense of context: of the moves from awareness of potential relationships between arts making and arts product and therapeutic change to the formation and establishment of the arts therapies as disciplines and as professions.

Introduction to Part IV Chapters 11 to 13 the movements and meetings described in Part III can be considered as a foregrounding of particular concerns to do with how the arts and therapeutic change are related. they refect the connections between the arts and discoveries and ideas emerging from disciplines such as psychology, the felds of psychoanalysis, psychotherapy and education. these connections are analysed further in Part IV, ‘Agents of transformation: arts, therapy, play’. Here three of the main areas that are brought together by much arts therapies theory and practice are looked at: the arts, the unconscious and play. they are, in many arts therapists’ eyes, key ‘agents’, or forces at work, within the arts therapies.

SNAPSHOT FROM CHAPTER 11 Potentials of the arts: ‘experienced culture’ the arts therapies . . . draw on the potentials of arts forms as experiences involving creativity and different kinds of qualities or opportunities for expression and relationship. they might, for example, use sound as a way of assisting or enriching communication for someone, or the potentials of image making to create connection between two people. Entering into the arts form within a safe space



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and within a therapeutic relationship allows aspects of a client’s ways of relating to be experienced differently, or the client can experience themselves differently. this might, for example, be true as a client with autism experiences communication with, and relationship to, another through paint, compared to words and eye-contact which are experienced as impossible routes. A number of arts therapists have stressed the importance of such participatory experiences of the arts in the arts therapies. It is this act of participation that can engender change through its experiencing rather than refecting or describing alone: ‘through such a group there is the possibility of rediscovering experienced culture, not just receiving a passive and often processed observation’ (Jennings, 1983: 49).

Many artistic movements of the early and mid-twentieth century gave credence and value to different, new experiences and voices, shifting them from the private worlds of asylum, dreams and nightmares onto canvas, stage, gallery and concert hall in an unprecedented fashion. such innovations will be analysed in chapter 12, ‘the sensuous encounter: the arts therapies and the unconscious’. this was not just one-way traffic – of the arts as practised by patients in asylums affecting the general world of the arts, for example. the introduction of the arts into hospitals also led to discoveries about the ways the arts seemed to affect patients within the hospitals. the experience of the arts in mental health contexts, for example, led to people seeing that the arts seemed to impact positively on the issues being experienced by patients. In addition, the effects of these exchanges between the arts and areas such as psychoanalysis were not confined to the arts practice alone. crucial to the arts therapies are the ways in which the arts influenced and featured within the development of psychoanalysis and psychotherapy, as well as changes in the field of education in many countries.

SNAPSHOT FROM CHAPTER 12 The sensual encounter the practice and methods of movements such as the surrealists or musical work emphasising atonality or improvisation have infuenced the artistic processes and languages within the arts therapies . . . Also, importantly, in their emphasis on the sensual encounter through the physical relationship with paint, clay, touch or sound, the arts therapies refect . . . discoveries and emphases in some twentiethcentury arts movements on the physical sensual encounter with the

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Introductions  

unconscious. this involves working in a way that is not rooted in verbal language alone, but in the physical senses engaged in the arts. the point here is that the arts therapies offer an additional aspect of contact through the relationship between physical, sensual acts such as dance movement or sculpture and the therapeutic encounter with unconscious material.

this book will review the varieties of arts processes within the arts therapies, and the ways in which discoveries about the arts have had an impact on the development and formation of the arts therapies. In particular, chapter 11, ‘the arts in the arts therapies’, will focus on this range. Also, chapter 13, ‘Playing, development and change’, explores the interaction between fields such as psychology and education in the development and current practice of the arts therapies.

SNAPSHOT FROM CHAPTER 13 I am the angry lion uK dramatherapist McAlister talks of a client, L, in an adult forensic setting. Initially they work within the sessions using story, object play and improvisation. However, the therapist notes of L: ‘he could not refect on it at all’ (1999: 107). Work continues over a number of months. the client becomes increasingly interested in objects such as boxes and shells. L had previously commented that the hospital at times felt like a container. this led into work around what aspects of himself the client felt needed to be contained by the hospital and the therapy, and what parts wanted to be free: Therapist’s account He was able to use objects to represent these things, the most significant being a small plastic dinosaur which he placed inside a box, fastened the lid and placed . . . underneath a table. this led him to begin talking for the first time about his violence when ill . . . Following this, L began using fences and boundaries to contain the dinosaur so that it was out in the open yet still contained. Again, these were themes that were returned to at later stages, as he continued to use various fierce animals to create stories about family groupings, zoos and captivity and reasons for



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his aggression. His capacity to make links between himself and session material gradually became much stronger. Eventually he was able to state ‘I am the angry lion. that’s me. I’m an angry man.’ (McAlister, 1999: 108)

chapter 14 provides a summary overview orienting some of the unique processes that the arts therapies offer. It reviews the many ways of working, and, within the diversity of art, music, drama and dance movement therapy, proposes a set of common-core processes: ‘From the triangular relationship to the active witness’. It argues that these help articulate the essential, different opportunities offered to clients by the arts therapies.

Introduction to Part V Chapters 15 to 17 since the turn of the twentieth century there has been a massive expansion within areas such as psychotherapy and parallel disciplines such as counselling, psychiatry and psychology alongside, within some countries, a continuity of traditional healing practices. Ways of working have been adapted within different cultural frameworks. the diversity and extent of provision have expanded through health services and practices all over the world, and their ideas and discoveries have echoed through many other felds. How does this growth relate to the emergence of the arts therapies? the full nature of this relationship and its relevance to the arts therapies will be discussed throughout this book, but especially in Part V, ‘the client–therapist relationship: paradigms, dialogues and discoveries’. At this point, I want to consider briefly some of the key aspects of the development and emergence of the field in relation to the formation of the arts therapies as a way of reflecting the themes in Part V. the emergence of areas such as psychotherapy is relevant to the arts therapies as they share aspects of a common background. this has three main components: 1 2 3

A general root of ideas and assumptions the establishing of the field of therapy as a way of creating positive change specific aspects of the field that start to discover links between therapeutic change and the arts.

the shared roots concern the variety of ideas and notions emerging as the fields of psychoanalysis and psychotherapy developed. the explorations

12

Introductions  

and discoveries about identity, change and the therapeutic relationship affected many fields, as we have seen, including the arts. Many arts therapists would echo Jung in saying: ‘Psychology and the study of art will always have to turn to one another for help, and the one will not invalidate the other’ (Jung, in Ghiselin, 1952: 209). What does this turning towards each other involve? It is possible to say that the ‘therapeutic roots’ of significant aspects of the arts therapies relate to different areas of discovery and development in the field of therapy. As this book will illustrate, dialogue and mutual discovery are occurring between the arts therapies and different approaches to therapy, from the psychoanalytic or humanistic, to the developmental and to mindfulness and neuroscience. this will be looked at in detail in chapters 15 and 16, which focus on different aspects of the client–therapist relationship.

SNAPSHOT FROM CHAPTER 15 Interview with Kalmanowitz and Ho on the Inhabited Studio: the client–therapist relationship Participants attending the ‘Inhabited studio’ were refugees and asylum seekers from different countries, including somalia, Iran and Liberia (Kalmanowitz and Ho, 2016). they were all clients of a nongovernmental organisation (nGo) in Hong Kong, which worked with the practical and psychosocial needs of refugees . . . referred to the studio as they had sought emotional or psychosocial support. . . . the Inhabited studio was named after ‘a fundamental principle in common between the art therapy and mindfulness – the practice of being in the present moment in an accepting and non-judgemental manner’ (2016: 59). In the studio art materials were made available and introduced to the participants but no theme was given. At the same time, mindfulness was introduced ‘through teaching of a variety of formal and informal mindfulness exercises’ (2016: 59). [. . .] JonEs:

You mention the importance of ‘viewing of thoughts as thoughts rather than reality’ (2016: 60) within the work. How did you see your role as art therapist in relation to this? KALMAnoWItz And Ho: Viewing of thoughts as thoughts rather than reality implies an ability to create a distance between oneself and the emotion, experience or thought. this is perhaps an untraditional response in therapy. A more traditional approach would be to facilitate the expression of the feeling or the thought/ memory and move towards working this through. the practice



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of mindfulness meditation reminds us that just as important as expression is the ability to gain some distance. With distance the individual is less overwhelmed and more likely to be able to begin to assimilate that which is diffcult.

Both the Handbook of Dramatherapy (Jennings et al., 1994: 15) and the Handbook of Art Therapy (case and dalley, 1992: 59) in their sections on the process of therapy in the arts therapies refer to the same material from psychotherapist cox and his definition of therapy as: ‘A process in which the patient is enabled to do for himself what he cannot do on his own. the therapist does not do it for him, but he cannot do it without the therapist’ (1978: 45). Both handbooks have independently drawn attention to this, as it is of central importance to the ways many arts therapists understand their practice. However, the arts therapies have made a number of discoveries about how arts processes and art forms create new opportunities and reveal new aspects of this relationship. this has led to innovative approaches and to new opportunities for clients in therapy. the development of the arts therapies has not always been a smooth or easy entry into the field of healthcare. Indeed, for some practitioners, any notion of assimilation is problematic. they see the arts therapies emergence as questioning the medical model. Mcniff, for example, says that the field of the arts therapies: can revolutionise therapy, and its transformative impact will be realised only if it continuously offers a radically different paradigm. the excessive reliance on chemical therapies, hierarchical control, and other institutional practices of ‘health’ have to be looked at from a completely foreign perspective in order to be seen. (McNiff, 1992: 11) this echoes clarkson’s perspective on change: that it can come from the most unlikely of connections and unexpected directions. she adds that change demands that the areas that something connects to and emerges from become different: ‘A characteristic of revolutionary change is that the starting conditions and basic components of the system have to be changed, and (these) may even appear out of the regions of probable predictions’ (clarkson, 1994: 10). one of the tensions present in writing about the arts therapies concerns whether, and how, the arts therapies offer a radical challenge to mainstream health services, or whether they should work within existing systems and adopt their languages and therapeutic frameworks accordingly to enable service user access. Mcniff argues that once the arts therapies accommodate themselves to these approaches and systems, and become assimilated into them, they lose their ability to provide a radical

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Introductions  

perspective. others have worked hard and long to enable arts therapists to practise within the major systems of healthcare provision. As this book will describe, there is now extensive provision offered to clients in the mainstream healthcare systems within many countries. these complexities are considered in chapters 15 and 16 which examine the nature of the therapeutic relationship and process within the arts therapies, drawing on research from different parts of the world.

SNAPSHOT FROM CHAPTER 16 Interview with Harris based on dance/movement therapy research fostering resilience and recovery among African adolescent torture survivors HArrIs:

these young people found in their traditional dances, which they taught me at my request, a source of great pride and power. At the same time, many of them were drawn to new cultural practices and values, as represented by classmates they were coming to know in school or meeting socially elsewhere. coming together to dance, to reconstitute the typical dancing circle, almost to transport themselves back to the heart of their culture of origin, afforded these young dinka an unusual degree of support . . . JonEs: In retrospect, how much did the experience of work/research change you as a dance movement therapist? What did you and the clients learn together that was new, taking the edge of the feld forward? HArrIs: In both of these programmes, I worked with African adolescents who had lost nearly everything themselves, most especially the love and nurturance of family support that are so critical to shaping identity in collectivist cultures. dancing together proved to be an exceptionally powerful engine for encouraging attachment and healing in the aftermath of such loss and violation, as has been shown in dMt for decades from chace onwards. this work demonstrates, perhaps, that dMt may be usefully adapted for application in diverse cultural contexts, at least among youths from sub-saharan Africa.

chapter 17 continues the debate about the nature of the dialogue between arts and therapy practice, as it looks at the ways in which change in the arts therapies can be understood, accounted for and communicated in ‘Efficacy: what works in the art gallery? What works in the clinic?’



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SNAPSHOT FROM CHAPTER 17 Efficacies A client . . . comes out of one of a series of music therapy sessions feeling that something has changed, but that they can’t put whatever is happening into words: they are wondering whether to continue with the therapy. At this moment, they are making a choice based on their experience of therapy and their opinion about effcacy. A department of mental health, in conjunction with a university research faculty, undertakes research on the outcomes of dance movement therapy in a series of hospitals within a trust using a randomised control trial design. their research may have funding implications for the future of the provision of the arts therapy in the trust and also wider implications for national and international knowledge and provision. Part of their research concerns whether, and how, such outcomes can be reproduced elsewhere by other practitioners and clients. clearly the needs and approaches for client and therapist are related but different in these examples. . . . the common aspect [here] and in every piece of work that takes place, from private therapy session to more formal research, is that the area of effcacy plays a crucial role in all arts therapies practice. some would see a continuum existing between the informal and formal procedures in everyday clinical practice and formal clinical research projects. others, as we will see, might argue that they are separate and have very different values.

Overview over the past century, then, a series of connections have developed into a particular form: the arts therapies. this book will look at the ways clients are offered new opportunities, of using the therapy space to work creatively, to develop and to change. the arts therapies have emerged from an explosion of experimentation and exploration. We can say that the current situation of the established practice of the arts therapies is both an evolution and a revolution in healthcare and the arts. this book will now go on to look at the development, practice and ideas within the emerging felds of art, music, drama and dance movement therapy.

PART II

The arTs Therapies: definiTions and developmenTs any definitions must be still in process – they are developing maps that show where the disciplines have been, where they are now, and where the arts therapies are going. That is why the following sections answer the question: ‘What are the arts therapies?’ by taking definitions and asking what they show us about different contexts, ways of working and developments, rather than simply reporting what they say. Jones, from Chapter 2, page 23

two

defnitions in fux: contexts and aims Introduction a single defnition for the arts therapies wouldn’t be useful to anyone. There must be different defnitions in response to different demands. This is not an indication of confusion, or a lack of clarity. rather, it’s a recognition that a national or international accreditation board or a client and arts therapist working together in a day centre have different needs in terms of defnitions. a music therapist beginning practice in india and one in ireland may have aspects of a defnition of music therapy in common, for example. however, they may also have needs that must be met differently in terms of defning what it is they do, and how it can offer change to meet local conditions. as we will see, my research has not discovered a single overarching defnition that has become widely used. The situation is one where there is a lively, rigorous diversity meeting different situations and needs. Within this variety, though, the development of the arts therapies within health services in the past fifty years has seen two main needs met in terms of definition. 1

2

one need has been for global definitions that fit national or international demands. This has been in response to the establishment of services and organisations functioning within national health provision, or to define a broad spectrum of practice covering all the disciplines of music, art, drama and dance. This kind of definition marks the coming together of smaller groupings to form large coalitions: necessary in establishing standards of professional training and practice at a state, national or international level. The second relates to more locally focused or nuanced definitions. These serve the needs of particular client contexts such as forensic or educational services, or individual health centres, and even specific groups run in such settings.

By paying attention to these different layers of definition we can gain some sense of the ways the arts therapies are seen: not only from a countrywide 18



  Definitions in flux: contexts and aims

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or international perspective, but also at a grass-roots level. This way of looking at definitions of the arts therapies will show how the broadest of pictures can be created and, at the opposite end of the spectrum, we will also understand some of the ways clients and therapists in different countries see their specific practice. This is not to say these need to be vastly at odds with each other, but, as we will see, different facets of the arts therapies show through in these various approaches to answering the same question: what are the arts therapies?

Arriving at definitions The national Coalition of Creative arts Therapies associations (nCCaTa) in the Usa goes about answering the question with one of the broadest of defnitions. The arts therapies involve: arts modalities and creative processes during intentional intervention in therapeutic, rehabilitative, community, or educational settings to foster health, communication, and expression; [they] promote the integration of physical, emotional, cognitive, and social functioning; enhance self awareness; and facilitate change. (NCCATA website) The UK’s national institute for health and Care excellence (niCe) offers a parallel broad definition: arts therapies are complex interventions that combine psychotherapeutic techniques with activities aimed at promoting creative expression. in all arts therapies: • • • •

the creative process is used to facilitate self-expression within a specific therapeutic framework the aesthetic form is used to ‘contain’ and give meaning to the service user’s experience the artistic medium is used as a bridge to verbal dialogue and insight-based psychological development if appropriate the aim is to enable the patient to experience him/herself differently and develop new ways of relating to others. (NICE, 2014: Section 9.3)

here are many of the themes that can be found in most of the definitions – art forms are linked to health, therapy and well-being, with some of the intended outcomes stated. These two definitions try to meet the needs of

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finding common ground between different art forms – they need to cover music, art, drama and dance movement, as well as serving an enormous range of health contexts and kinds of provision. hence they give a sense of the overall processes at work. similar wide-ranging definitions come from organisations and professionals working across disciplines: music, art, drama and dance movement therapy. in some countries, such as the Usa and the netherlands, organisations covering all art forms operate in parallel to others focusing on specific disciplines such as music or art therapy. in the early 1960s, for example, the Nederlandse Vereniging voor Kreatieve Therapie (netherlands society for Creative Therapy) was formed alongside the netherlands art Therapy society (Jones, 2007). YahaT, the israeli association of Creative and expressive Therapies, says simply that ‘creative and expressive therapies is an overall name used to describe creative and expressive processes from the fields of art used in treating emotional, developmental and organic disorders’ (YahaT website). another example of a broad approach is that taken by the Us national expressive Therapy association (UsneTa), founded in the 1970s. This association focuses on what it calls ‘expressive therapy’ and ‘expressive arts therapy’ rather than the individual arts therapies (UsneTa website). here all the arts are brought together under one umbrella, their common quality described as ‘expressive’. The nCCaTa, by contrast, doesn’t claim that all arts therapies can be included in this way; it, rather, notes connection and difference: ‘although unique and distinct from one another, the creative arts therapies share related processes and goals. participation in all the creative arts therapies provides people with . . . ways to express themselves that may not be possible through more traditional therapies’ (nCCaTa website). as we will see, this echoes the stance taken in many countries, where the arts therapies are divided into separate, but related, professions of art, music, drama or dance movement therapy. There are arts therapists practising round the world. in different countries there are diverse levels of training and practice. many accounts describe the growth in number of arts therapists. Gaines and Butler note that in north america, for example, by 2014 there were 700 ‘active members’ of the national association for drama Therapy, marking a growth of a third in a decade (2016: 61). The recognition and status of the arts therapies within health services also varies enormously. This can have a bearing on how arts therapy practice is seen and accessed by clients. The range is considerable – from Brazil, for example, where music therapists have been training since the 1970s, and there were 1,500 music therapy graduates by the early twenty-first century (smith, 2003), to Korea where, by the same date, 15 music therapists who had trained abroad were working (Kim, 2002). one of the earliest associations of arts therapists was founded in 1950: the Us national association for music Therapy. The american dance Therapy association (adTa), formed in 1966, notes that by the start of the twenty-first century its membership included over 1,200 dance movement therapists in 46 states of the Usa and 29 foreign countries (adTa website).



  Definitions in flux: contexts and aims

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each of these associations have developed in response to individuals coming together and forming groups – from the smallest initial meetings of people exploring the potentials of the field to these much larger, established associations. definitions are the outcome of these groupings negotiating with each other, and with clients and organisations who will use their services. some have evolved their own definitions; others have adapted or adopted existing ones. one of the newer definitions created by such a grouping of individuals has emerged from Taiwan. By 2003 Taiwanese dramatherapists had developed this definition for their use: dramatherapy is an involvement in drama with the intention to facilitate growth and changes based on individual needs. dramatherapy is deeply rooted in the therapeutic aspects of drama. dramatherapy uses the human potential for expression. The expression here is both the process and the aim of dramatherapy. it enables the client to achieve a new relationship towards the problem or life experience. (Chang, interview, 2003) This definition was a part of the process of creating a dramatherapy association for the first time in Taiwan. in a later interview Chih hao Chang revealed the way in which, after reaching a definition, he and others who wished to form an association recognised by the Taiwanese government needed to follow specific procedures: our government set up a law titled the Psychologist’s Act in 2001. This protected professional titles so that only certain professions could use specific terms: this meant that others, such as dramatherapists undertake master’s study in counselling or psychotherapy in order to be a qualified psychotherapist, then they can practice their dramatherapy work. some of dramatherapists have to change their word ‘dramatherapy’ into ‘mental development’, ‘mental health’ . . . and so on, or co-work with psychotherapists or social workers. in 2013, we set up the Taiwan drama resilience association to develop our profession of dramatherapy. in may 2019 many expressive art therapists, including art therapists, dramatherapists, dance movement therapists and music therapists have started to fight for recognition by approaching the Taiwan ministry of health and Welfare to initiate recognition by law through an Expressive Arts Therapies Act, which will enable us to work using the word ‘therapy’. (Chang, interview, 2019) here we see a snapshot of a pattern that has emerged in different countries as the arts therapies have grown. a small group of interested and trained

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Arts therapies: definitions, developments  

people are gathering together to develop definitions, identities, professional governance and recognition relating to their discipline and practice. in similar ways, different subgroups or professional groupings of arts therapists have arrived at their own descriptions. some of these are identified by their theoretical orientation – for example ‘art psychotherapy’ (Wadeson, 1980). malchiodi has written about the development of art therapy in relation to people dealing with physical illness. she defines the term ‘medical art therapy’ as the ‘use of expression and imagery with individuals who are physically ill, experiencing trauma to the body, or who are undergoing aggressive medical treatment such as surgery or chemotherapy’ (malchiodi, 1993: 66). others are generated by their practice context – such as prisons or education. it’s interesting to look at some of these, as they give an indication of the way in which different contexts refine the broader strokes of the national or international definitions. looking at development in the UK, for example, a document created by the standing Committee on the arts in prisons (sCap) said that: The arts Therapies provide a radical way of using the arts as rehabilitative as opposed to occupational services for offenders. The forensic nature of our work lies in our potential to facilitate creative investigations with inmates as our clients. (SCAP, 1997: 6) The arts therapies are talked about as a whole in the document, as well as being differentiated as art, dance movement, drama or music. These arts therapists acknowledged that whilst they shared theoretical foundations, the ‘specialisms’ differ in the ways in which therapeutic aims are achieved. in the quote above, you can see how the idea that those within the prison system can have therapy made available to them as a specific rehabilitative process is focused on, and also the notion of creativity as an ‘investigation’. all of these facets of the definition show how particular aspects of the arts therapies can be foregrounded to relate to a context. in this instance they are the ways in which the arts therapies can be used to rehabilitate and to investigate issues as part of the work of a forensic setting. increasingly there is interest in how clients in therapy define the nature and effect of the arts therapies. for example, research in australia included the perspectives of young people aged 16–25 who ‘were facing mental health challenges’ (Gwinner, 2016: 12): What a lot of people get out of art work is, like, if something is disturbing them like, let’s just say they got assaulted once and it was traumatising for them, and they don’t want to tell anyone about it cause it is their secret. They put it into artwork it helps them get it out (Young person).



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[i] saw it more as, like a, i suppose mindfulness exercise. i like thinking, so thinking and introspection is always a big theme for me, so that’s why i enjoyed it (Young person). (Gwinner, 2016: 13) as the researcher notes, such perspectives ‘will not lead to a unifying definition, theory or framework of art, therapy and health’ (2016: 15), however, these insights enable the field better to understand how clients make sense and communicate the nature of the arts therapies. They also assist in the field becoming more inclusive, in that such published research enables those using the therapy to have their voice acknowledged in defining the area. Gwinner argues that the young person in the first quotation validates ‘the role of art as therapy in that it offered a psychodynamic approach with a focus on supporting the release and integration of emotional anxieties and a way to express past disturbing experiences in doing art’ (2016: 13) and in the second quotation that, ‘art was also nuanced as a method for expanding self-awareness’ (2016: 13). The two testimonies included here, then, enable us to see how meaning making and connections are being made and how clients help the field articulate the nature of the arts as therapy. one of the points i’m making is that a definition in the arts therapies shouldn’t be something set in stone, that is immovable. The arts therapies naturally need to evolve and change. as disciplines in the early years of their establishment within contemporary health services, we are still discovering much about what they can do and how, or why, they are effective. so, any definitions must be still in process – they are developing maps that show where the disciplines have been, where they are now, and where the arts therapies are going. That is why the following sections answer the question: ‘What are the arts therapies?’ by taking definitions and asking what they show us about different contexts, ways of working and developments, rather than simply reporting what they say.

Settings and contexts: an overview all the arts therapies work with groups and with individuals. arts therapists practice on their own or in departments, in multidisciplinary teams and in a freelance capacity. The size of arts therapies groups varies: they are normally between three and twelve, though, as we will see, in some countries groups can be as large as ffty or more. all the arts therapies stress that they can be used by anyone, and are not in any way oriented towards those perceived to have talent or interest in the art form, or that referral is for those whose issues are seemingly related to the area of artistic expression. as payne points out, a common misconception about dance movement therapy (dmT), for example, is that it is ‘only for those clients

24

Arts therapies: definitions, developments  

with physical diffculties such as co-ordination problems; that only people with a natural talent for rhythm or movement should attend dmT’ (payne, 1992: 5). Broadly speaking, arts therapists work in a wide variety of settings the world over. most aspects of healthcare and educational provision have been worked in, and are documented within recorded practice. from the early days when the arts therapies were often focused in areas such as mental health or with clients with learning disabilities, their work has expanded into most aspects of the human condition: from pre-school to work with the elderly, from medical wards to prison rehabilitation, from private practice to state provision. The american art Therapy association (aaTa) lists an extremely diverse range of contexts: from hospitals, outpatient clinics and schools, to halfway houses and pain centres. Work has taken place involving people with addictions, living with cancer, and those who have been bereaved. as this book will show, the arts therapies have proved flexible and adaptable, meeting the capacities and needs of a broad range of clients, from people with attention deficit disorders to those with mental health problems such as psychosis or schizophrenia. The extent of practice can be limited by attitude, availability of therapists and systems of healthcare, alongside the economic and political situation. Kim (2002: 1) noted that in Korea, for example, music therapists face opposition not only from sceptical and defensive professionals in related fields, but also from the effects of the economic collapse within the country, and the recoil of political instability: We do not have a secure well-established welfare system and our national health insurance does not cover for alternative and creative therapies. Therefore, most clients for music therapy are privately funded. many psychiatric hospitals in Korea have some form of creative arts therapy program, especially music therapy, but social workers and nurses run most of these programs. however, gradually, institutions are opening up towards the music therapy profession more readily than ever before. (Kim, 2002: 1) sajnani notes the importance of context and political and cultural frameworks in considering the nature and role of the arts therapies; she argues for the need for greater awareness of how culture and power connects to the encounter between client and therapist: so that clinicians are better able to actively reflect on how implicit and explicit biases are expressed in their own lives and in the lives of their clients, within and beyond the therapeutic encounter . . . shifting our attention from the individual to society in the construction, treatment and



  Definitions in flux: contexts and aims

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prevention of psychopathology, and privileging transparency and shared authority in the therapeutic relationship. (Sajnani, 2016: 148) she identifies a need for the ‘inclusion of multicultural education in training contexts’ (2016: 148). nebe, for example, speaking of the innovative drama for life training in dramatherapy in south africa notes that ‘illness in africa, as a social construct, doesn’t embody the same Western, scientific interpretations that are entrenched in our post-colonial, mainstream mental-health system. rather we understand illness within a holistic, body–mind–spirit continuum’ (nebe, 2016: 353). okazaki-sakaue reflects on the social–cultural context of the arts therapies in Japan: the general attitude is that you must be extremely ill to receive therapy, and that, though the need for psychiatric treatment in urban areas is increasing, psychotherapeutic approaches are not well accepted. she notes that the approach to music therapy, for example, tends towards a medical or behavioural approach, with little music-centred or psychodynamic work taking place. she says that goals tend to be group- or family-oriented, not in the service of an individual, referring to practice where some music therapists work with as many as fifty people in a group and call it a therapy session. okazaki-sakaue points to other cultural issues: i have found that there are also some cultural and social issues with seniority rules both in clinical practice and training. for example, children do not call their therapists by their own names, but rather as ‘sensei’ (Teacher) and this does impact on aspects of the therapeutic relationship. also grown ups are expected to control their emotions and not express them openly. This sometimes works against the typical therapeutic goal of ‘promoting self-expression’. (Okazaki-Sakaue, 2003: 2) here we can see illustrated the way the arts therapies try not only to respond to local needs and frameworks of health, but also how they are affected by some of the tensions between different attitudes and understandings. okazaki-sakaue is drawing our attention to some of the tension experienced between a therapeutic goal and the culture he is working within. arts therapists such as Boston and short see such issues as rooted in differences between cultural concepts such as identity, the arts and change. some of the issues described by okazaki-sakaue are paralleled in their definition of an afrocentric, in contrast to a eurocentric, position on the arts therapies. in general terms, Boston and short typify the eurocentric world view as stressing individuality, uniqueness and differences, the afrocentric as being represented by ‘groupness, sameness and communality. The values and customs are co-operation, collective responsibility and interdependence’ (1998: 37). They discuss this in the context of african american

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Arts therapies: definitions, developments  

clients and therapists, and the importance of art therapy recognising the impact of ‘the african american heritage of the tribe, slavery, the need for practical application of therapy that acknowledges and validates the unique ethnic background of clients’ (Boston and short, 1998: 47). so, one way of seeing okazaki-sakaue’s comments regarding the definition and the provision of arts therapies is to understand them in the context of different cultural issues within a society, concerning how therapy should be provided. some of these are to do with fundamental areas such as views on identity, the expression of feelings and the way the need for help is seen. arts therapists such as Boston and short (1998) and others (Clarkson, 2002b), have pointed out that the connections between issues concerning spiritual or religious matters are often left out of considerations to do with definitions of client and therapist experiences within therapy: many agencies are very clear to keep religion out of sessions, out of schools and out of government as much as possible. in the african american community, religion is prevalent and it is just as prevalent in the art work as religious symbols and topics often surface spontaneously in art therapy sessions. (Boston and Short, 1998: 46) They echo comments saying that clinical work is flawed if spiritual matters are not addressed. Clarkson argues for the importance of acknowledging the ‘spiritual, mystical, transcendent or numinous’ aspects of living and areas within the therapeutic relationship. she adds that this is especially important as ‘there can be no multicultural psychotherapy without some kind of respectful relationship with the religious and spiritual practices in which many, if not most, cultures are steeped’ (Clarkson, 2002b: 8–9). for the arts therapies these are especially important points to hear, given the relationships between art, music, drama and dance and many forms of religious experience and practice. The arts therapeutic relationship, some would argue, is also connected to the ways in which participation in arts processes such as dancing, or making music, may connect to spiritual matters for client and therapist alike. Given that the arts therapies are now practised in many different cultural arenas, as these illustrations show, it is unlikely that one definition will satisfy the range of needs such contexts require. The following sections try to include definitions from a number of contexts in recognition of this diversity.

Different modalities Whilst arts therapists practise in similar settings, there can be differences in emphasis across the different modalities of art, music, dance movement and drama. Within the UK, for example, Karkou’s small-scale research



  Definitions in flux: contexts and aims

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indicates that for dance movement therapists educational settings are the main working environment, whereas for music therapists they are the second most common, and for dramatherapists the third. There are proportionally far more therapists from these disciplines practising in education than art therapists (Karkou, 1999b: 64). The main employment setting for art therapists was within mental health services. Ways of working within settings also have many similarities, but also some differences. again, Karkou points out that from a small sample of arts therapists within education only 50 per cent of art therapists worked with groups compared to 80.6 per cent and 87.5 per cent for music therapy and dance movement therapy and 100 per cent for dramatherapy (Karkou, 1999b: 66). so, whilst contexts are broadly similar across disciplines, there may often be specifc differences in the extent and nature of some of the ways arts therapists practise according to their modality. more recently, Karkou has talked about the importance of the relationship between the arts therapies being one of collaboration: The strengths of the one discipline can be added to the strengths of the other, creating a professional front that operates on the basis of mutual respect for one’s unique practice, experience and potential contribution. . . . such collaborations do not challenge professional identities but add value, offer better services to clients, safeguard professionals from potential isolation, and . . . add an enormous amount of enjoyment and excitement. (Karkou, 2016: 10) This book’s scholarship is motivated by the spirit of such collaboration: the value of interdisciplinary dialogue and mutual discovery. What, then, are the differences and similarities between the arts therapies? The next chapters explore definitions and ways of working in each of the arts therapies and explores the relationships between them.

three

What is art therapy?

Definitions The American Art Therapy Association (AATA) roots its approach to art therapy in a belief that the creative process involved in the making of art is healing and life-enhancing. It defnes art therapy as: an integrative mental health and human services profession that enriches the lives of individuals, families, and communities through active art-making, creative process, applied psychological theory, and human experience within a psychotherapeutic relationship. Art Therapy, facilitated by a professional art therapist, effectively supports personal and relational treatment goals as well as community concerns. Art Therapy is used to improve cognitive and sensorymotor functions, foster self-esteem and self-awareness, cultivate emotional resilience, promote insight, enhance social skills, reduce and resolve conflicts and distress, and advance societal and ecological change. (AATA website, 2017) Here are elements common to many definitions of art therapy: concepts of health, or healing, are connected to active involvement in art within a professional relationship, alongside an identification of some of the ways in which client and therapist might experience the impact of the therapy. The Brazilian Association for Art Therapy defines it in a similar manner, as a way of working with ‘artistic expression’ to enable ‘client–professional communication’ with its ‘essence’ as ‘aesthetic creation and artistic elaboration on behalf of health’ (Associação Brasileira de Arteterapia, 2017). Art therapy has changed significantly since its early beginnings, with a diversity of directions growing from these common elements. Within the UK, for example, there is a strong influence from psychoanalytic and psychodynamic theory in contemporary practice (Schaverien, 1992; Karkou, 1999a). This is mirrored by the Art Therapy Association of Colorado (ATAC), which offers as its definition, ‘art therapy brings together psychotherapy and the healing qualities of the creative process’ (ATAC 28



  What is art therapy?

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website), and the Canadian Art Therapy Association (CATA) definition, which allies art directly to psychotherapy: ‘Art Therapy combines visual art and psychotherapy in a creative process using the created image as a foundation for self-exploration and understanding’ (CATA website, 2017). Behbehani analyses how art therapy in Kuwait interacts in its development with different cultural, aesthetic and political contexts. Art therapy services are defined broadly as addressing ‘many needs such as depression, anxiety, trauma-related issues, self-harm, self-medication, and learning disabilities’ by offering provision where ‘many traditional art therapy interventions are redesigned’, drawing on ‘abstract art’ rather than ‘figure drawing’ in an effort to ‘respect religious beliefs and accommodate cultural mores’ (2016: 739). The Canadian Art Therapy Association (CATA) emphasises the way thoughts and feelings often reach expression in images rather than words, and places this process within a psychotherapeutic model of change where ‘feelings and inner conflicts can be projected into visual form. In the creative act, conflict is re-experienced, resolved and integrated’ (CATA website). Here, then, the emphasis is on the notion of inner conflict and on art as a projective means through which re-experiencing is connected to resolution. Differences in the definition and practice of art therapy exist both within and between individual countries. In Germany the general term in use is similar to the English ‘art therapy’: Kunsttherapie; but there are other terms used, such as Maltherapie (painting therapy), Kunstpsychotherapie (art psychotherapy) and Therapie durch Medien (therapy through media) (Herrmann, 2000: 19). These indicate different approaches or ideas about change within the overall discipline. The definition of the British Association of Art Therapists (BAAT) reflects a broad and inclusive approach to defining art therapy: Although influenced by psychoanalysis, art therapists have been inspired by theories such as attachment-based psychotherapy and have developed a broad range of client-centred approaches such as psycho-educational, mindfulness and mentalization-based treatments, compassion-focussed and cognitive analytic therapies, and socially engaged practice. (BAAT, 2017) After declaring that clients do not need to have experience or skill in art, it makes a statement that marks a difference from other forms of therapy: The relationship between the therapist and the client is of central importance, but art therapy differs from other psychological therapies in that it is a three way process between the client, the therapist and the image or artefact. It offers the opportunity for expression and communication

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Arts therapies: definitions, developments   and can be particularly helpful to people who find it hard to express their thoughts and feelings verbally. (BAAT, 2017)

From early theory and practice, through to contemporary attitudes, this triad of therapist, client and ‘image or artefact’ has been a developing theme in articulating the nature of art therapy. In 1958, for example, Naumburg described work in this way: ‘The images produced are a form of communication between patient and therapist; [they] constitute symbolic speech’ (Naumburg, 1958: 561). The art in art therapy is often defined in a broad way: ‘this activity ranges from the child scribbling to express himself, to . . . working with clay to the graphic painting by a woman deeply depressed’ (Dalley, 1984: 97). The art materials can vary widely depending on factors such as artistic choice or availability. Waller, for example, makes the point that within the introduction of art therapy practice in Bulgarian contexts, ‘traditional’ art materials were both scarce and expensive: ‘Instead, scrap material, such as old boxes, magazines, string, wool, old toys and clothes, were assembled and decorators’ shops were located where useful oxides, tints, glues, large tubs of emulsion paints and brushes etc. provided the basic source of colour’ (Waller, 1995: 230). Malchiodi and Johnson (2012) and Choo (2015) have written on the uses of new technology, the creation of a ‘virtual art studio’ and digital media environments as art therapy. The art form within art therapy is still developing: creating and responding to new cultural dynamics.

Aims of art therapy The diversity of defnition is refected in the variety of ways that aims are formulated: they can vary from being related to a specifc context of practice, through to a much broader, national perspective. An example of aims specifc to a setting are those defned by Wald in relation to her work in a rehabilitation context with clients who have had strokes. She says that art therapy goals for ‘stroke survivors’ include: • • • • • •

improving the patient’s awareness of individual problems teaching compensatory techniques to deal with deficits improving functional, manipulative ability assisting the patient to mourn, grieve and accept change in body image supporting a patient’s efforts to work through their emotional reaction to their losses and limitations providing a non-verbal visual means of communication, self-expression and interpersonal exchange. (from Wald, 1999: 36)

The aims above are edited down from the list Wald devised. These few, however, illustrate the wide range of attention given, including areas relating



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to physical rehabilitation through to the exploration of feelings, perceptions and relationships. They show an awareness of, and a response to, the particular therapeutic needs of a specific client population. Wood et al.’s (2013) survey of art therapy clients in cancer care provision parallels this attention in its account of clients’ sense of the aims of art therapy. The research found that service users found art therapy helpful (92 per cent), and their feedback concerned its positive direction in their lives concerning ‘coping’, ‘aiding communication’, helping with the ‘expression of feelings’, providing new perspectives and offering distraction from worries related to their experiences of cancer. Members of the Canadian Art Therapy Association talk of the broad, general aims of art therapy as using ‘imagery, colour and shape as part of this creative therapeutic process’ to help clients in a variety of ways. The following offers a sample of these: •

• • •

•

•

Through the use of art making, discussions and reflections on the artwork, and relationship building, art therapists support individuals in problem solving, developing insights and self awareness, improving self-esteem, managing stress, and enhancing interpersonal skills Encourages creativity, and supports the individual to connect with inner strengths and develop alternative responses to stressors and problems Provides visual focus for reality-orientation and non-verbal means of communication for individuals dealing with loss of cognitive and language abilities Engages all the senses to relax the nervous system. Art making causes a shift from sympathetic to parasympathetic nervous system, which results in improved self regulation, anxiety reduction, feeling more in control, improved executive functioning Research shows that trauma is stored in the brain as a sensory experience, with fragments of images and sensations, rather than a cognitive, coherent narrative. A sensory experience such as art therapy can thus provide a vehicle for externalizing traumatic experiences and releasing tension Making verbal expression more accessible. (CATA website, 2017)

Such aims emphasise the capacity of art in therapy to express and communicate feelings, to work with, and through, areas of difficulty and to facilitate reflection and discussion. Art therapist Cameron talks about her work in conflict resolution with people who were homeless in New York City in a way that illustrates these aims in relation to a specific context. She sees homelessness within a broad framework, including the breakdown of the family, a lack of skills or education, unemployment, despair and the availability of guns and drugs. These ‘all contribute to the inability to sustain a home’ (Cameron, 1996: 183). The therapy took place in a setting working with ‘street homeless’ who have been living in parks and subways. Art therapy was part of a broad arts programme within a structured

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Arts therapies: definitions, developments  

rehabilitation process. The rehabilitation recognised that for many of the clients homelessness, trauma and violence were interconnected, and that after basic needs such as food and shelter were addressed, there was a need for ‘healing, insight, creative problem solving and conflict resolution’ (Cameron, 1996: 185). She notes that for some of the participants the traumatic experiences meant that they could not risk failure, and had developed what she calls ‘self-destructive ways of coping’. One of the facets of this noted by her was a common pattern of conflict in their relationships with others. The aims of the art therapy were to relieve stress, to teach participants to express themselves through different art media, and to ‘process’ problems, violent reactions and self-destructive thoughts. The group involved ten participants, lasted for six weeks and was funded under a ‘Stop the Violence’ initiative. The practice involved a variety of ways of working and included directive use of image making. Cameron, for example, says that she wanted to find out what ‘Stop the Violence’ meant to each participant: In two sessions I expressly asked them to depict a violent episode, and I also reminded them intermittently to include any altercations from their week. However, I always left the first piece of each session open in order to find out how they were being affected, if at all, by this art experience, what their real issues were, and how they personally related to violence . . . This was followed by a stress reduction exercise, then they painted another piece and the group ended with sharing and discussion. At this point we noted the differences between the pieces, how their states of mind related to their everyday living, and their relationship with themselves and others. (Cameron, 1996: 188) The close of the sessions was marked by an exhibition of work, along with the final statements of the participants, written on cards by one of the group. Comments included: It has opened up a channel of my life that is inspirational. Painting made me aware of options that I couldn’t see when I started to paint. I felt the art class put me in control of my situation without criticism. I am always being viewed and judged, but this time I was doing the viewing . . . I got a chance to explore my ideas and what I feel. (Cameron, 1996: 204–5) If we look at the aims of the work, they can be summarised as relating to a combination of the art therapy having an effect on behaviour, offering opportunities for insight and reflection, and ‘teaching’ clients art language



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and processes. The client feedback seems to indicate that their experiences reflect these aims, in that they write of being given access to painting, and that this is linked to reflecting on their lives, and to being inspired. The ways Cameron works include sessions in which she gives a structure – there is painting followed by stress-reduction exercises, followed by more painting and reflection. She also introduces activities with an instruction on the broad topic, or theme, of painting activity, in order to assist clients and herself focus on the area for which the group is created through funding and identified need. Here the artwork produced by clients is initiated by a given direction. The properties of art making are seen as relevant to therapy as a way of enabling clients to access aspects of their experience, and to facilitate change. Difficulties within the clients’ lives are focused on by the therapist – first through the nature of referral and the brief for the group, and secondly through a direct invitation to explore material on a given theme through image making. Images produced are reflected on, by the individual who made them, and by others within the group – both therapist and clients. There is seen to be value in the creation of art as a way of exploring difficulties, the process of being within a group, the relationship with a therapist, along with opportunities for reflection on the connections between images, the clients’ life experiences and change. It’s interesting to note the way one of the clients quoted describes the sessions as an art ‘class’. This is not uncommon within the arts therapies, in that it might indicate a client trying to describe the work through the more familiar terms of teaching. Perhaps it was also an indication of the client feeling more at ease with the notion of attending sessions oriented towards learning art skills rather than personal exploration. Perhaps, also, the approach taken by Cameron felt akin to a directive approach that teaching can take in classes, rather than the more open-ended approaches of non-directive art therapy where subjects, activities and reflection are much less likely to be provided by the therapist. The work culminates in an exhibition of words and images. Though Cameron doesn’t comment on the therapeutic purpose of this, other art therapists have pointed to exhibiting work as an option within art therapy. Some art therapists see aims and ways of working rather differently from this therapeutic approach. They would argue that if the therapist structures the art therapy session by deciding factors such as when and for how long the individual, or group, should paint, the therapist is in danger of being ‘too controlling and thus interfering with the transference’ (Skaife, 1990: 238). Skaife gives an example of a different approach in a group art therapy context. The description comes from the fifteenth month of the group. There were six members and one member of the group was absent, some were late: R told S, as the last person in the group to know, that he was leaving. He gave his reasons as financial; his changing circumstances meant that he could no longer afford

34

Arts therapies: definitions, developments   both group and individual therapy. He was keeping on the individual therapy as he needed some support and he felt the group could not offer enough of it. E asked if he was disappointed in the group. R said that he was mainly disappointed in himself, but he was disappointed that there was not more painting in the group and he reminded everyone that he had said this all along. E said that she too would like to do more painting and that she had joined the group so that she would have the opportunity to express herself by painting. There was a general moan about the difficulty of getting down to painting. I said that I felt there was a wish in the group that I should tell them when to paint and to offer more structure to the group. Perhaps this seemed even more frustrating since I had made a rule about B and S not meeting before the group. I wondered if the recent absenteeism and lateness might be a means of getting me to lay down more rules. B said he’d hate me to be like a mum telling them what to do. H contradicted my interpretation and said that the lateness and absenteeism must be to do with R leaving . . . They returned to the subject of painting. H said that I should be telling them ‘how to do it’. What was the point of my being in the group? They could have anyone in off the street if they had to do it themselves. H said that she felt I was withholding my special knowledge. (Skaife, 1990: 240)

The group continue to discuss painting and not painting. Issues are raised – such as the time after painting being valuable to talk, how frustrating some members find not having time to discuss all the images. Skaife reminds them that it is possible to return to images the following week, and refers back to the previous week’s creation of images of biting mouths. One of the clients says that she is afraid to paint because she fears the chaos, and it makes her feel that she understands nothing. The therapist notes to the group that each member had said that they wanted to paint, and that some had suggested painting, but that no one seemed to want to follow anyone’s lead. She offers an interpretation that this might be due to some competitiveness in the group, perhaps concerning envy if one person’s idea is taken up. A suggestion comes from the group, B saying that he didn’t want to steal H’s idea, and supports the idea of a group painting. The clients go about this: They set to and painted with lots of energy . . . They were very aware of each other . . . B, although he started painting boldly in his own space, soon left it and was merged with the others. There was lots of red paint going on and they kept painting over each other’s work. At first S appeared to



  What is art therapy?

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be the only one painting figuratively. R looked very excited and was playing with black paint. H kept in her own space and painted a skyscape and a Scottie dog on it. All of a sudden they stopped as if they were afraid of the language of the paint taking over. E complained that her crocodile had been submerged: its biting jaws had been painted over by R, who said he had not been aware that it was a crocodile. (Skaife, 1990: 241) Skaife shows here how, by not taking a directive approach to starting or stopping painting, or giving subject matter to the group directly, areas of group and individual process open up. Themes such as group members caring about others’ opinions and issues of power are engendered and explored. These come to the fore, ‘by my taking an analytic role rather than a leadership role’ (Skaife, 1990: 242). The area is seen by her as being to do with clients giving up dependent patterns and taking on power. Themes are identified by Skaife as including a challenge to the therapist, being directly angry, whilst at the same time being afraid of abandonment and being left to the aggressive impulses of one another. Isolation and merging are seen as possible themes within the group. Skaife describes S’s voiced fears of being isolated in the picture making, and that no one would come near her; she created an image that protected her face with surrounded crosses. Skaife notes, ‘Merging with others, while on the one hand relieving one from feelings of isolation, also involves a loss of individuality’ (Skaife, 1990: 243). She argues that by allowing the group to make decisions on how and when they should change activity, issues such as the use of time, being alone and being part of the group are brought into focus. The group’s experience of its own process becomes highlighted through this way of working with ‘a dual emphasis on the self determination of group members, since this is expressed not only through their paintings but also through the form that the group takes’ (Skaife, 1990: 244). In both examples we can see illustrated one of the defining characteristics of art therapy: the relationship between client, therapist and art object or process. Evans bases his description of art therapy on this: The art process and the way it is used in therapy is central and an essence of the practice. For in my definition of art therapy the art process is engaged with in the presence of, and to some extent, in response to . . . the therapist. This takes outside of art therapy that which some have called ‘spontaneous art therapy’, where individuals have discovered art/image making and found it therapeutic without the intermediary of the therapist . . . It also excludes . . . persons bringing imagery into [psycho] therapy for analysis and comment. (Evans, 1982: 114–15)

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Arts therapies: definitions, developments  

The issue of directive compared to non-directive approaches is one that receives a good deal of attention in art therapy writing and definition. Practitioners vary – some therapists working mainly with one or the other approach, whilst others modify their practice within sessions, or within the process of work, depending on the needs of the client or client group. For example, Murphy (1998) conducted research through questionnaires with British art therapists working with sexually abused children and young people. She was exploring, in part, the methods and approaches used. Of the therapists responding, most were engaged in individual work, with a quarter also offering groupwork. Of these therapists, 60 per cent said that they worked in a way that was described as non-directive. The rationale behind working non-directively was that the sexually abused client needed to feel in control, and that direction from the therapist could feel intrusive. In addition, respondents said that clients making their own choices of art materials developed self-confidence and taking control, and formed part of the therapeutic process. In contrast, Lobban’s (2016) report on US art therapy with military veterans found that a directive approach was often used: ‘in general, directives are used to provide structure for the art therapy group sessions at most of the departments I visited’ (2016: 19). Art therapy was offered as part of wider treatment programmes, with aims such as ‘the development of independent, creative problem-solving skills and the possibility of connecting with other veterans’ (2016: 19). In one of the sites visited within the research, ‘art therapy is part of a four week intensive programme for small groups of service members, who live on campus with their families for the duration of the programme’ (2016: 16). The veterans attend a weekly two-hour art therapy group session, with each week having a different theme. The directive for week one, for example, is to decorate a papier mâché mask where ‘participants are invited to think about personal identity and to make a creative response’ (2016: 16) and week four involves creating ‘a montage on canvas’ (2016: 17). Theme-based art therapy is framed here by notions such as being adopted ‘to enable veterans to make gradual progress towards the expression and processing of difficult material’ (2016: 17). The work is connected by the art therapists and by Lobban to research such as that by Belkofer and Konopka (2008) where, ‘patterns of electrical brain activity were measured before and after art-making, which revealed higher frequencies of brain activity in the temporal lobes after art-making. The temporal lobes play an important role in experiencing a sense of meaning, connections to a higher power and deep feelings of peace. This suggested potential for accessing a deeper level of self-awareness through art therapy’ (Lobban, 2016: 28). Lobban’s summary positions such theme-based work as: Art therapy can assist the working through of each cluster of PTSD symptoms by: Reducing hyper-arousal through increased self-awareness; trigger discrimination; and creative absorption. Overcoming avoidance and increasing distress tolerance through image-making and reflective discussion, providing an alternative route to understanding and resolving problems.



  What is art therapy?

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Facilitating a reduction in re-experiencing symptoms through creative exposure and increased insight. Challenging negative cognitions through meaningmaking; breaking the cycle of rumination; and discovering new ways of seeing and perceiving. (Lobban, 2016: 35) Here we can see the ways in which differences in approach are understood to offer clients different opportunities. The art therapist’s role, the therapy space and the art form are not offered to the client from one perspective only. Developments have seen work emerge exploring the relationship between art therapy mindfulness and studio work for women who were refugees, exploring political violence, trauma and resilience (Kalmanowitz, 2016) and in dialogue with neurobiological theory in art therapy designed to facilitate ‘trauma narrative processing’, ‘autobiographical coherency’ and the rebalancing of ‘dysregulated responses to psychosocial stressors and trauma impacts’ (Hass-Cohen et al., 2014: 69). The American Art Therapy Association sees its members’ approach to practice as wide-ranging. It says that art therapy utilises art media, images, the creative art process and client responses to products as reflections of an individual’s development, abilities, personality, interests, concerns and conflicts. It says the knowledge underpinning the work is rooted in a variety of sources and includes developmental and psychological theory, educational, psychodynamic, cognitive and transpersonal perspectives. It states the broad aims as ‘reconciling emotional conflicts, fostering self awareness, developing social skills, managing behavior, solving problems, reducing anxiety, aiding reality orientation and increasing self esteem’ (AATA website FAQs). Bromberg’s survey of 386 members of the AATA in the New York area seems to echo much of the association’s recognition of diverse approaches and ways of working. The survey asked about practice with cancer patients. Part of it looked at the ‘theoretical approaches’ of art therapy practitioners in this area of work. It revealed that no one theoretical approach was preferred. The diversity of theoretical approach indicated gestalt, behavioural, cognitive, psychoanalytic, Jungian and object relations being cited at similar levels (Bromberg, 2000). This variety of orientation in practice is echoed in BAAT’s description of an art therapist. This refers to key areas of the training of an art therapist as including the psychology of mark making and symbolism, non-verbal communication, a psychotherapeutic understanding of child development and family dynamics. The Association argues that art therapists draw on their knowledge of these diverse areas to enable change for the people they work with. Lanham captures something present in all these definitions when he argues that the products of art therapy, though they may not be seen in public, are as essential as any ‘great’ work of art in art galleries: They may, even when kept in a drawer, have a real life and meaning for the person or group involved in their creation

38

Arts therapies: definitions, developments   and through this make a greater contribution to our society . . . this broader concept of art, including all creative utterances by all people, is not a new one. It is only within the development of Western civilisation, where the artist has achieved the status of myth in his own right, that the art of the unknown or anonymous person has been ignored by society. (Lanham, 1989: 21)

The examples we’ve looked at have shown us that art therapy can enable this ‘broader concept of art’ and the relationship between client, art process and product and therapist to develop in many different ways in diverse settings. Aldridge gives an interesting example of this flexibility and ingenuity in terms of art therapy occurring in a sink: Tom, aged seven, was attending an art therapy group as part of social services care and is described as living in a situation of poverty. He: liked to paint the large sink in the art room with his brown mixture made of all the paints mixed together. He respected the boundary imposed of only painting on the tiles and sink. He mixed the colours with the group and then painted the sink; when he’d finished he’d name the sink according to the colour – they were called shit, vomit, diarrhoea, piss, sick. These sinks took nearly three quarters of an hour to complete as they were very carefully painted so that none of the white showed through. (Aldridge, 1998: 2–9) We can say, then, that the ways in which art therapy occurs varies according to the client/patient group or individual, the context and the therapist. This recognises the reality of the situations of many arts therapists: they may work in settings with different orientations, whose clients may be best served by a particular approach. Some art therapists work within a particular therapeutic framework, whilst others maintain a dialogue with different theories. However, as the BAAT definition recognises, a common denominator is that there is always an emphasis on creativity and the therapeutic relationship.

four

What is music therapy?

Definitions Blair points out a number of different aspects of music that are relevant to music therapy. He describes one of these elements as music’s impact on ‘the affective sides of our minds’ (Blair, 1987: 5). By this he means the ways music can affect mood, how it can relieve or create tension, for example. Another quality concerns music’s capacity to express ‘instincts’ and ‘complexes’ for the maker or composer, and also for the listener. Music as a form is open to the individual’s own interpretation and it can powerfully evoke ‘imagery of many kinds – realistic, fanciful or even hallucinatory – which may enable him temporarily to escape from the unacceptable world or reality’ (Blair, 1987: 5). Music also can be associated with important experiences in someone’s life, including ones that may have been forgotten or repressed. It can revive such memories, whether remembered or hidden. Blair refers to music’s association with community, and with its role in affecting relationships between people. In many societies music is associated with its capacity to ‘foster feelings of mysticism and reverence mak[ing] its use almost indispensable in religious rituals of all kinds’ (Blair, 1987: 5). He sees it as an important ‘agent’ of non-verbal communication and interpersonal relationships. In this respect he highlights, in particular, its capacity to arouse empathy between people, to increase self-esteem and enhance social contact. These qualities of music would be recognised by many clients and professionals involved with music therapy. They are touched on in the different definitions and uses of music in therapy. Priestley’s definition is simple and wide-ranging: ‘Music therapy is an art, and as such, a very personal and creative form of work’ (Priestley, 1975: 15). He says that there are three main activities in music therapy: making musical sound and expression on instruments or with the voice, listening to music with the therapist, and movement to music. This broad range of activity is reflected in several definitions. Edwards (2016) notes a variety of approaches and models including, for example, that of Nordoff Robbins. She cites Aigen’s summary of this model as being primarily music-centred: ‘in music-centered music therapy, the mechanisms 39

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Arts therapies: definitions, developments  

of music therapy process are located in the forces, experiences, processes, and structures of music’ (Aigen, 2005: 18). Another illustration of this variety is ‘developmental music therapy’, described by Edwards as involving clinicians using aspects of developmental theory to elaborate and explain the rationale for their practice: for example, concerning how music connects with client developmental needs. Psychodynamic music therapy, as a further example, proposes that with the assistance of music, human beings can become aware of their inner states, and can communicate these through musical expression. From a psychoanalytic viewpoint, music is considered to portray meaning and to give the individual the feeling of being mirrored, accompanied and even personally understood (Edwards, 2016). Aluede (2010) notes this diversity from a different perspective, referring to the presence in his country of the ‘age old tradition of music in the restoration of health’, and how ‘in Nigeria, there exist different kinds of therapies’ and different kinds of contexts for ‘the use of music . . . for healing purposes. Therefore it is not out of place to hear in common and everyday English, terms like music in therapy, music as therapy or music therapy. Used in whichever way, it points to the therapeutic potency of music’ (2010: 36). The New Zealand Society for Music Therapy (NZSMT) says that music therapy is ‘the planned use of music to assist the healing and personal growth of people with identified emotional, intellectual, physical or social needs’. The Society emphasises the potentials of music within a therapeutic relationship to develop communication, extend language and intellectual development, and to give support in times of emotional challenge. The range extends from music’s role in rehabilitation, to improving movement and physical coordination, through to music’s capacity in therapy to assist memory, imagination and thought, and to enhance spiritual and cultural identity (NZSMT website, 2017). The Florida Association for Music Therapy (FAMT) echoes many of these ideas in its definition of ‘music and music activities both in treatment programs which address the physical, emotional, social and cognitive challenges faced by children and adults with diverse illnesses and special needs, and in wellness programs which promote the maintenance of good health in the general population’ (FAMT website, 2017). The American Music Therapy Association (AMTA) takes a similar, broad approach, saying that music therapists ‘design’ music sessions for individuals and groups using music improvisation, receptive music listening, song writing, lyric discussion, music and imagery, music performance and learning through music (AMTA website). The British Society for Music Therapy (BSMT) foregrounds the therapeutic relationship: There are different approaches to the use of music therapy. Depending on the needs of the client and the orientation of the therapist, different aspects of the work may be emphasised. Fundamental to all approaches, however, is the development of a relationship between the client and

What is music therapy?

41

the therapist. Music making forms the basis for communication in the relationship. (BSMT website) The UK Standing Committee of Arts Therapies Professions (SCATP) also emphasised relationship, stating that music therapy: provides a framework for the building of a mutual relationship between client and therapist through which the music therapist will communicate with the client, finding a musical idiom . . . [that] . . . enables change to occur . . . By using skilled and creative musicianship in a clinical setting, the therapist seeks to establish an interaction – a shared musical experience – leading to the pursuit of therapeutic goals. (SCATP, 1989: 6) Barcellos’s (2001) and Wagner’s (2007) reviews of music therapy in Latin America note the diversity of definitions, emphasising dialogue between transnational and localised articulation. Both, for example, describe the ways in which psychoanalytic thinking and music therapy have developed together in dialogue with ‘factors idiosyncratic to the Argentine people and culture’ (Wagner, 2007: 146) in work such as that by Benenzon (2007). In a later interview, Wagner talks about this context in terms of challenges in Argentinean society: ‘music therapy was part of this changing world’ giving, as an example, how it developed to meet clients’ ‘psychosocial needs due to economic difficulties’ (2009: 1). Barcellos offers another illustration of this differentiation, noting how in Brazilian music therapy: The principal instruments are those which come from Brazilian folklore, although all musical instruments can be used, even instruments originating in different cultures . . . the instruments which are part of the country’s folk culture, are selected and used with ease by the patients. Dances, games and other aspects of folk culture are performed by patients and by therapists with patients and are well accepted by them. (Barcellos, 2001: 2) Pavlicevic et al. (2014) refer to Aigen (2005) in their discussion of work with clients with severe learning disabilities and the nature of music therapy: The link between musical and personal experiences is elaborated in Aigen’s (2005) ‘Music-Centered Music Therapy’, which clarifies the multiplicity of live musical experience. Aigen writes: ‘The reason why the specifics of the music are so important in music-centered music work is that the

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Arts therapies: definitions, developments   musical process is the personal process, and understanding, or at least experiencing, the music can provide insight into the nature of the clinical experience for clients who cannot report this themselves. As importantly, it can do so in a way that is not mediated through the client’s particular way of describing the experience. (Aigen, 2005: 96, cited in Pavlicevic et al., 2014: 7)

Accordingly, they argue, music therapists ‘read’ the musical as the personal and, through therapeutic improvisation, offer ‘shared musical experiences’ that have particular ‘resonances for those with less access to communicative and expressive verbal language’ (2014: 7). All these potentials are seen to be available to anyone, irrespective of musical skill. Wigram echoes Payne’s earlier point cited in Chapter 2, about dance movement therapy, as he notes that it is not uncommon for people to assume that musical ability is necessary for referral to music therapy: ‘some people may still think they are referring someone to music therapy for musical activities, development of musical skills, or just to make them happy’ (Wigram, 2002: 13). The capacity to make music is one that is assumed to be a potential in anyone, and the ways in which music can feature in their therapy can reflect a broad variety of therapeutic needs and aims. Participation need not be connected to any perceived inclination to be able to create music.

Aims of music therapy What kinds of aims does music therapy have? These vary widely, as we have seen with art therapy, but here are illustrations from Japan, Northern Ireland, Bosnia and Australia, which also draw on interviews with music therapists by Skewes (2002) in New York to illustrate something of the ways in which music therapy aims are seen. Music therapy is cited, for example, as being used to help alleviate pain in conjunction with anaesthesia or pain medication, in counteracting depression, in promoting movement in rehabilitation settings, to stimulate intellectual, social or emotional functioning and memory, to strengthen communication and coordination, to explore personal feelings and to resolve conflicts (Bunt, 1997). The Mostar Music Centre (MMC) cites the aims of music therapy as being to engage individuals in growth, development and behavioural change, and to transfer musical and non-musical skills to other aspects of their lives. They stress the potential of music to help bring people from isolation into active engagement with their world. They say that music therapy aims to: • •

facilitate creative expression in people who are either non-verbal or who have deficits in communication skills provide the opportunity for experiences that can open the way for and motivate learning in all domains of functioning

What is music therapy? • •

43

create the opportunity for positive, successful and pleasurable social experiences not otherwise available to them develop awareness of self, others and environment and improve functioning on all levels, enhancing well-being and fostering independent living.

Here we can see an emphasis on enabling communication, providing reparative or motivating experiences, and increasing functioning or awareness. These aims are oriented towards well-being, contact and independence. It’s interesting that the process of music seems absent here; the emphasis is on the language of behavioural change (MMC website, 2017). Aims vary from those that focus on music’s relationship with physiological change, to those relating to the capacity Blair speaks of in terms of music’s effects on relationships, and to those concerning processes relating to exploring emotions, memories and personal experiences from the present or past. Tateno and Ikuko (1982) describe work starting in 1970 in Japan using the potential of singing and whistling in conjunction with breathing exercises. It aimed to relieve the physical symptoms for children with asthma. This was developed into work using singing and taped music to help children develop their breathing and response to respiratory attacks (Tateno and Ikuko, 1982: 2–10). Okazaki-Sakaue makes a general point about this perspective: he states that the approaches within Japan emphasise medical/ biological and behavioural aspects of practice, with little evidence of what he calls psychodynamic or music-centred approaches (Okazaki-Sakaue, 2003: 2). Cosgriff, working in Northern Ireland with people with Parkinsonism, collaborated with a consultant neurologist and a physiotherapist. Parkinsonism is cited as resulting in neurophysiological disturbances such as muscular rigidity and tremor, facial immobility, difficulties in moving and walking, and restlessness. Music therapy aimed to assess the effect of music on walking, movement, tremor and speech. It was observed that music provided motivation and rhythmic stimulus to initiate movement, increase mobility and assist in the control of voluntary movements. The therapy also aimed to use music to induce a state of relaxation that could reduce involuntary movements and permit increased control of voluntary movement (Cosgriff, 1986: 14). Meetings lasted for two hours over a number of weeks. Improvised piano music along with guided imagery was used. A series of movements for upper limb functioning, standing, balancing, turning and dancing was used along with group singing and the use of percussive instruments. It was found that ‘group dynamics and the use of instruments promoted activity beyond many people’s described capabilities. Whilst playing percussion instruments all the participants were able to extend upper limb function considerably’ (Cosgriff, 1986: 17). Group members used music outside the session to accompany activities – having discovered that music seemed to assist them. Playing music whilst shaving, for example, impeded ‘freezing’ (Cosgriff, 1986: 17). The emphasis of this work is on behavioural, physical effect.

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Arts therapies: definitions, developments  

Australian music therapist Dawes (1987) talks about music therapy in a way that encompasses the wider range of aims spoken of earlier by Blair and Bunt. Her work encompasses goals that relate to physical, intellectual and psychosocial functioning. She says that the aims particularly try to address the needs of clients who would ‘benefit from an alternative approach in counselling, involving increased opportunities for non-verbal expression of emotional responses to their life situation’ (Dawes, 1987: 4). This is linked to three distinct approaches to counselling-oriented music therapy, environmental music and activity-oriented music therapy. Environmental music aims to influence and enhance the situation of clients. She cites a series of tapes created by the music therapist to be played to clients in order to assist in the reduction of ‘general agitation and choreic movements’ (Dawes, 1987: 4). The aims of the activity-oriented music therapy are to improve and maintain physical, intellectual and psychosocial functioning. The emphasis here is on non-verbal and verbal communication, or cognitive skills such as memory, concentration, relaxation and social interaction. The therapy might involve listening to music, singing or musical games and activities. One such example is conducted by a music therapist and a physiotherapist. The music therapist provides improvised music on a piano and piano-accordion ‘to support the dynamics of movement and to create an appropriate atmosphere. The music is designed to elicit individual responses from members of the group and the essence of the movement generated by one person (in particular activities) for the group to take up’ (Dawes, 1987: 8). The aim of the counselling-oriented music therapy is to ‘improve/maintain levels of psychosocial functioning’ (Dawes, 1987: 4), emphasising communication, self-expression and self-esteem in work with individuals and groups. Some of the examples of this she gives concerns people who are sustaining loss of physical and intellectual capacities as part of aging, for example, where therapy can concern a deterioration of relationships with friends, family members and familiar or meaningful activities. A common phenomenon is the decreasing ability to communicate verbally – in areas such as the client’s emotional response to their life situation. In group therapy within her practice, a typical session might consist of an activity encouraging group members to identify with one another, and to create a supportive atmosphere. This might take the form of an opening song chosen by the group, or a physical warm-up to music with a strong rhythm. After this, the structure is relatively free form – songs might be introduced by the group or by an individual. Dawes says that the choice of song reflects the group’s, or individual’s, emotional state. Emotions and issues raised by songs – for example, by lyrics – are discussed. An example of this might be the ending of relationships. The choice of song material might then be directed by the therapist to encourage participants to analyse their response to issues raised. Later sessions tended to have a larger component of improvisational music. This is seen to express emotion non-verbally and the therapist may offer interpretations of the music. It is stressed that interpretations are suggestions, and can be accepted or rejected:

What is music therapy?

45

Music is used as a catalyst for discussion and emotional out-pouring; a vehicle for emotional expression . . . Sessions tend to follow a pattern of confrontation, followed by reflection, then recreation . . . expressed by music. Comments by members of such groups have indicated that they find the atmosphere of these sessions makes it easier to ‘share together’, and that they can participate on differing individual levels both verbally and non-verbally. (Dawes, 1987: 6) Music therapy group improvisation is described by Skewes (2002) as ‘a powerful tool for working with groups of clients who do not communicate successfully using verbal means’ and for ‘gaining insight into self and their relationships with others’ (Skewes, 2002: 46). She interviewed nine music therapists in New York. Some of the aims behind the ways of working in New York mirror the examples from Japan, Northern Ireland and Australia. Group improvisation in music was seen by the New York therapists to encourage people to express themselves freely and spontaneously, to create interaction and to result in a unique manner of interacting with other group members. This was seen to allow members to discover new aspects of themselves, and to express something musically that might be new and surprising. Participants could use musical improvisation, and the relationship it created with others, to role-rehearse new behaviours within the group. Music here is seen to provide an opportunity to experience different things. As with Blair’s comments on evoking ‘instincts’ or ‘complexes’, the therapists say that within music making it is possible to use the momentum of the group sound to move through a range of emotional states and feelings, and to achieve benefit in acknowledging and expressing these aspects of the self. Making music is seen as an expression of the self, and this individual self-expression as an important aspect of music therapy (Skewes, 2002: 49–50). The awareness of the connections between the client’s sense of self, the music and the relationship with the therapist enhances the possibility of ‘learning’ and ‘growing’ from experience. The therapists observed that ‘where words are specific and exact, music offers the opportunity to express abstract ideas and amorphous feelings’, and can help express things that ‘have not been worked out yet’ (Skewes, 2002: 49). What do these definitions tell us? The examples and descriptions assert that music can offer safety because of its complementarity to words; it can contain and express powerful feelings; music can link to spiritual matters, the ‘transpersonal world of the soul’ (Skewes, 2002: 49). Music has its own meanings and relationship to feelings: fluidity between physical, emotional and cognitive can be aimed for and achieved. It allows participants to live in the moment and to allow permissions outside of their normal experience of themselves. In focus group activity relating to Bunt, Burns and Turton’s work, clients gave feedback on their experiences of music therapy. It reflected many of the key themes this review has touched on. This included comments that changes of mood within music being listened

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Arts therapies: definitions, developments  

to had a ‘knock-on’ effect both emotionally and physically; that playing music enabled people to feel more confident, fresher after the experience. They also said that playing was powerful, energising and releasing for some, relaxing for other group members, and that participating with others created positive effects, helping people to sense what others were feeling and thinking (Bunt et al., 2000: 67).

five

What is dramatherapy?

Definitions Haythorne and Seymour situate dramatherapy as connected to a developing understanding of how ‘the skills and means of making theatre can be fexible, mobile and inestimable in their scope’ (2017: 2). They situate the concept of client voice as central to the feld, that ‘in dramatherapy the client learns that their “voice” is respected and valued and the therapist is the . . . audience or “witness” to what they want to show’ (2017: 2). Casson’s research in the UK looked at dramatherapy with clients with mental health problems who were encountering auditory hallucinations, and who had a variety of diagnoses including schizophrenia and paranoid schizophrenia. They were asked about their opinions of their ongoing dramatherapy work. Client comments included: It’s active, fun, motivating – when you’re down, or have low self-esteem it’s uplifting and brings you out of your shell. Dave: The great thing about these groups . . . is that you are free to be what you want – an adult, a child, thoughtful, fippant, sad, happy, you have freedom gained from shared and directed trust to be anything . . . I haven’t played since a small child feeling intimidated, scared, guilty; responsible and alone . . . if voices are stress related then by alleviating the stress as happens in the group, then it’s very useful . . . one of the problems with medication is that it fattens your emotions; it induces a tranquillity of sorts but this is more like a numbness or hollow feeling . . . writing, painting or John Casson’s dramatherapy group are important to maintain your sense of self as a human being and to realise that emotions can be expressed in a positive way without having to suppress everything and resulting in even more emotional fattening and long term psychological illness . . . CHeryll:

47

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Arts therapies: definitions, developments   only when I started dramatherapy was I able to state how I felt . . . [dramatherapy] helps you to do the healing yourself, to be instrumental in helping yourself, empowering rather than just taking medication. (Casson, 2001: 23–4)

GlorIa:

Many of these clients stress the active, physically participatory nature of the therapy as being one of the key aspects they feel to have been important in change for them (Jennings, 2010). The participatory elements of drama can be seen in Nigerian dramatherapist adeyinka’s (2013) framing of the discipline as containing improvisation, spontaneity, imagination, empathy, playfulness, intuitiveness, emotional sensitivity and role-play. The Chilean Drama Therapy association also foreground active, time-based processes facilitated by the therapist involving ‘verbal and physical expression, movement, dramatic action, staging, dramatisation and ritualisation of group dynamics’ (www.edras.cl/dramaterapia). These qualities are echoed, in part, in the North american Drama Therapy association’s (NaDTa) description of dramatherapy as an experiential approach: Dramatherapy facilitates the client to: • • • • • • • •

tell their story solve problems set goals express feelings appropriately achieve catharsis extend the depth and breadth of inner experience improve interpersonal skills and relationships expand their repertoire of dramatic roles to find that their own life roles have been strengthened. (NaDTa website)

Its broad definition sees dramatherapy as working towards symptom relief, emotional and physical integration and personal growth (NaDTa website). There is an emphasis on setting goals, solving problems, finding how to express feelings appropriately, interpersonal skills and performing roles with more flexibility. Many would see this as foregrounding processes that tend towards a cognitive approach to change, with its emphasis on determining goals, problem solving, performing roles and expressing feelings ‘appropriately’. other languages of therapy are reflected, however, in the general areas of exploration and ‘inner experience’ cited. The British association of Dramatherapists (BaDth) gives a broad definition that emphasises the healing potentials present in drama and theatre, with the therapeutic process being described in terms of creativity, imagination, learning, insight and growth (BaDth website). It describes dramatherapy as a form of psychological therapy in which all of the performance arts are utilised within the therapeutic relationship. Some have stressed the role of creativity within dramatherapy as being at the heart of change: ‘It is the client’s creativity as developed, expressed

What is dramatherapy?

49

and explored within the therapeutic framework, and the focused dramatic processes, which provide the opportunity for health and . . . change’ (Jones, 2007: 5). Dramatherapy facilitates change through drama processes (Jennings, 1997). It uses the potential of drama to reflect and transform life experiences to enable clients to express and work through problems they are encountering, or to maintain a client’s well-being and health (Pitruzzella, 2004). a connection is made between the client’s inner world, problematic situation or life experience and the activity in the dramatherapy session: ‘clients make use of the content of drama activities, the process of creating enactments, and the relationships formed between those taking part in the work within a therapeutic framework’ (Jones, 2007: 6). Holmwood makes direct comparisons between the therapy space and that of theatre: ‘the playing with internal scripts is akin to playing with theatrical scripts and . . . the therapist and client become director and actor’ (2016: 163). He frames dramatherapy as involving the therapist engaging with clients to ‘continually adapt theatrical traditions in differing culturally specific forms to bring about a space where potential curative creativity can take place’ (2016: 168). Sajnani also creates parallels between drama, theatre and drama as therapy, but focuses on social, cultural and political dynamics. She argues that ‘drama and theatre serve to re-sensitize us to ourselves, to each other, and to the possibilities available to us in every social interaction’, connecting this to how ‘drama therapy may be used to help those we work with notice those aspects of themselves and others that have been denied, shamed and kept hidden from view, practice being in relationship to others amidst differences (of opinion, position, perspective, location etc.), and imagine, rehearse, and incorporate options for action’ (Sajnani et al., 2017: 35). Pendzik and raviv emphasise the therapy space as enabling interaction between imaginary and ‘everyday’ reality: Drama therapy thrives on imagination. In fact, a central therapeutic tool in drama therapy is the capacity to ‘download’ the world of imagination in the here and now in such a way that it is experienced as almost real. Through the use of dramatic reality, drama therapists add a complementary dimension to everyday reality – one which concretizes the subjective realm of imagination in the physical space, allowing it to be legitimized, explored, mastered, and transformed. (Pendzik and Raviv, 2011: 269) valente and Fontana’s research consulted UK dramatherapists on their views and ways of working. Part of this concerned factors that therapists considered relevant for final assessment in dramatherapy. This gives us an overall idea of the kinds of areas seen by them as connected to change or outcomes. Those most frequently indicated were as follows: • • • •

Self-esteem Self-awareness Self-acceptance Self-confidence

50 • • • • • •

Arts therapies: definitions, developments   Hope Communication Trust Self–other awareness Spontaneity Social interaction (valente and Fontana, 1993, 1997)

valente and Fontana draw attention to the cluster of variables to do with ‘the self’. Part of their conclusions based on the research is that the general goals of dramatherapy place an emphasis on the client’s achieving emotional openness, perception, creativity and self-acceptance. The researchers say that this can be seen as giving an indication of what UK therapists feel is most amenable to change through dramatherapy. Pitruzzella develops this concept, arguing that at the heart of dramatherapy is a ‘dramatic model of personmaking’ that involves ‘seeing the person as a more dynamic and complex system, immersed in an ever-changing world of relationships’ (2016b: 275), referring as an example to improvisation in dramatherapy and its role in helping ‘people to live in the moment, making continuous, joyful exchanges with others, fostering relationships and mutual listening’ (2016: 283). andersen-Warren and Grainger have said that ‘dramatherapy means the therapy that is in drama itself – all drama – and not merely the use of some aspects of drama as therapeutic tools’ (2000: 15). areas within the realm of drama include improvisation, play-based processes, role play, mask, puppetry, drama games, voice work and script. Snow et al. (2017), for example, have explored the role of participation in what they term ‘therapeutic theatre’ and how it can bring about self-confidence and positive self regard. Some forms such as role play and those rooted in psychodrama emphasise a direct replaying of reality (Pitruzzella, 2016a). others using story, myth, image and movement stress the creation of metaphors or symbols to enable the client to explore material. of this latter type the Sesame approach, developed by lindkvist in the UK, is typical (Hougham and Jones, 2017). It aims to work obliquely through metaphor; the emphasis is on recognising and dealing with client material through indirect expression (Hougham, 2017). Smail talks about, for example, the role of ‘the distancing protection of story text, role, image and gesture’ and how they ‘allow meaning to spontaneously emerge so that, for a time, the participant can enter a world that affirms them’ (2016: 182).

Aims of dramatherapy The Irish association of Creative arts Therapists (IaCaT) gives the general aims of dramatherapy as being to: • •

stimulate imagination and the development of personal expressive skills in an enjoyable way creatively explore ideas, issues and problems by using drama activities

What is dramatherapy? • • • •

51

explore real-life relationships and social situations through the fictional mode of drama promote multisensory learning foster developments of positive communication, cooperative sharing and social skills develop concepts of responsibility for the self and other in relationships, so as to promote increased self-esteem, confidence and changed ways of functioning. (IaCaT)

This definition of aims tends towards a cognitive or behavioural approach to change, with its emphasis on learning, or the development of skills, capacities and problem resolution in five out of the six aims. Creativity is linked to learning, and seen as a means of changing ways of functioning in terms of self-esteem, cooperation, social skills and communication. Notions of positivity and enjoyment within the work are seen, within this definition of aims, as a part of stimulating and assisting learning-based and developmental processes in therapy. Dramatherapist Dokter saw clients for group dramatherapy in an eating disorder unit. She had asked clients initially to look at their expectations or fears and ran an assessment activity to look at their situation and interpersonal relationships: Clients select objects from a basket with shells, stones, wood and other natural objects. The objects represent significant people in their life and themselves. They then sculpt these objects in relation to each other; close, far, on top etc. . . . The sculpt is threefold; present, a significant past moment and some time in the hoped-for future (the client decides how far ahead this future is). I then . . . asked [for] the first small change clients might wish for in the near future. This provided a good stepping stone to discuss the client’s aims for themselves. (Dokter, 1996: 186) The work included what Dokter describes as projective techniques such as sculpting, poetry and storytelling. She sees part of her approach as linked to a developmental understanding of her clients and their issues. She considers this as a way of looking at how the clients’ difficulties can be linked to a block or difficulty to do with development, and also in selecting a dramatic language and process to assist in revisiting and reworking the block the client originally encountered: Johnson proposes that movement, drama and verbalisation correspond with the sensorimotor, symbolic and reflective stages. This developmental perspective is useful for those clients who have been blocked in their development. For

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Arts therapies: definitions, developments   clients with eating disorders this blocking of their autonomy and difficulty with verbalisation certainly applies . . . [it] can . . . supply a guide for selecting the most appropriate structures and techniques. (Dokter, 1996: 188)

In addition, the work acknowledges that for many clients with eating disorders, what has been expressed non-verbally through the body can be very threatening to express in words: ‘The threat is to experience emotions often deadened by the obsessive preoccupation with food and body shape and/or the physical effects of “starvation and over-activity”’ (Dokter, 1996: 190). once the ‘pain’ is externalised, she argues, engagement with the underlying issues can begin: Clients used little figures to sculpt some of the important interpersonal events of their past week. The theme arising from these sculpts was . . . the clients’ total preoccupation with caring for others, losing themselves within the process. I suggested a continuum line, one pole the totally caring for others, the other pole total caring for oneself. I asked clients to select their preferred and feared places along the continuum and write some scenes connected with these points (past and present life events). These stories were then shared. (Dokter, 1996: 189) a ‘continuum’ involves the therapist creating an imaginary line across a room. The two poles of the line represent two different extremes on an issue. The continuum line, for example, might indicate anxiety on entering a new group. one end of the continuum might indicate an extremely high level of anxiety, the other no anxiety at all. Clients place themselves to communicate their own response. Dokter says that the continuum was used for the clients to explore their life and issues, rather than to rely on the therapist’s interpretation. It encouraged clients to look at alternative perceptions and interpretations made by the group, by the clients themselves. She says that her role primarily involved containment, and that too much direction would link to feelings of being controlled or manipulated. The approach is influenced both by a developmental and an insight-oriented approach to change. Dramatherapy here helps the clients to create perspective, to explore and make connections with material that would be difficult to access through words alone (Butler, 2017), and then to work through areas of their experiences which are developmentally needed (Jennings, 2010; read Johnson, 1999). So, for example, issues to do with caring – being cared for, and caring for others – are explored. Past experiences can be re-connected with, explored dramatically, and the client can gain insight and a new relationship to issues underlying the eating disorder. Here dramatherapy is seen as a way of powerfully evoking issues, experiences and areas within a client’s life. enactment enables feelings to be

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actively expressed and explored, but the dramatic language of using objects and stories enables the client to feel able to achieve enough distance to explore and acknowledge sensitive material. The exploration, once worked with in this way, can then be discussed or acknowledged and owned, rather than denied and acted out through the body. landy’s work in individual dramatherapy illustrates another approach to defining what dramatherapy can be, and how it offers change to a client. as part of ongoing work with ‘Sam’, landy (1997) describes the exploration of the client’s experience through looking at what he describes as ‘Sam’s role system’. The work took place weekly for fifty minutes each session over a three-year period. Some of the issues brought by Sam to therapy included his relationship with his father. He had become mentally and physically ill, and abandoned his family when Sam was aged 8, dying when Sam was in his early twenties. His mother had, in Sam’s terms, expected him to fulfil his father’s role in the family. Sam had been brought up within a fundamentalist Christian religion. He was suffering a breakdown in his marriage and was incapable of leaving: due, in part, to his religious beliefs. Initially landy uses a combination of story making, where the client makes up a story spontaneously, playing with small figures and objects in sand, choosing masks or puppets, and creating roles. Within this, the client and therapist begin to look for themes or roles that reflect problematic areas. The created roles are seen as a way of exploring Sam’s ‘inner life’, and the system of different roles gives an indication of the past and present concerns of the client. Issues emerge in this way and are summarised by landy as: ‘the murderous, exploitative father who is not what he appears, of women who are split into children, seductresses, and aggressors, of bravery and fear, of gatekeeping and setting boundaries’ (landy, 1997: 131). The aim of the therapy, at its simplest, landy states as being to help the client to explore their imaginative world of roles, and to relate it to their everyday life, to visit and revisit what landy calls unsafe inner territory: Sam played out many versions of heroes and villains, and saints and sinners, and bad fathers who tried to be good, and beautiful women who turned out to be beastly. a recurring image was that of the double, the disguise, the face beneath the mask. Sam created the sinning saint, based on the pastor who abandoned the church and maybe even based upon his father who abandoned him at the age of eight. He created the image of a flower with a long stem that was attached to a box containing an explosive charge. a detonator stuck out of the box, ready to discharge its explosive contents. He created, in a story, one of his most powerful characters, rupert Stosh, the good man who liked to do bad. Stosh, a demonic Nazi-type, appeared to be a wealthy, kindly philanthropist, but actually operated an

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Arts therapies: definitions, developments   underground slave labour nuclear plant. During this early stage, Sam and I became familiar with those role types that would dominate his psyche. (Landy, 1997: 133)

The client plays out many parts, exploring these roles and their relationship to himself. over time the playing of roles allows the client to gain insight into the past and present, and ways in which these roles reflect himself. He experiments with the roles, exploring different ways of seeing himself and being with others. For example, landy describes how this happens through the creation and exploration of dramas around characters such as rupert Stosh, or another role, Farmer Sam. Towards the end of the therapy landy notes, for example: ‘During our final months together, Sam was able to understand that farmer Sam and rupert Stosh, the secretly brutal men, though based upon his confusing parents, were fearful and shameful parts of himself’ (landy, 1997: 138). landy sees this as a key moment in change, as the client is no longer in ‘denial’ of his problematic relationships, his fear and shame. at the end of therapy, landy says that Sam had discovered a way to integrate his ‘many confusions and reconstruct a viable role system’. landy says that Sam came to mourn the loss of his denied childhood, and of his own father; he was able, through the therapy, to express feelings rather than to act them out in explosive, manic episodes, or implosive, depressive ones. landy concludes that, for Sam, drama became ‘a safe craft for many therapeutic voyages: it proffers an alternative reality, that of images and reflections, through its imaginary walls of distance shaped by fictional characters and stylised actions’ (landy, 1997: 141). Here we can see at work a number of the facets referred to at the beginning of this section, and identified by Casson’s clients: the process is active, as Sam engages imaginatively and physically in playing out roles; this in turn allows insight and the permission to try out being free to play roles differently. The work also validates the client’s sense of identity by dramatically exploring different aspects of the self, and people important to the client. By experimenting in playing different roles, or by playing roles differently, the therapy creates opportunities for emotions to become more positively expressed (Pitruzzella, 2016). It is possible to see, then, that active participation in encountering this dramatic world, of creating an alternative reality through the enactment of roles, or playing with objects, can empower the client (Seymour, 2009; Sajnani, 2016). The qualities of drama to reflect reality through playing or acting are utilised to enable clients to work actively through dramatic representations of their lives.

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What is dance movement therapy? Definitions Payne writes that ‘Dance Movement Therapy supports people whereby spontaneous movement is seen as symbolic of unconscious processes. It increases self-awareness and self-esteem, providing for growth, change and healing within a therapeutic relationship’ (1992: 2). Stanton-Jones (1992) and Meekums (2002) have attempted to summarise the theoretical principles underlying dance movement therapy. Their defnitions include the following: • • • • • •

The mind and body are in constant interaction Movement reflects personality: this includes psychological developmental processes as well as psychopathology and interpersonal patterns of relating The therapeutic relationship includes a non-verbal dimension Movement is symbolic, and evidences unconscious processes Improvisation in movement allows clients to experiment with new ways of being and relating Creative processes in free movement are inherently therapeutic. (Stanton-Jones, 1992: 10; Meekums, 2002: 8)

Dance Movement Therapy (DMT) is also known as Dance Movement Psychotherapy (DMP) or Movement Psychotherapy. The European Association of Dance Movement Therapy offers the following definition: the therapeutic use of movement to further the emotional, cognitive, physical, spiritual and social integration of the individual. Dance as body movement, creative expression and communication, is the core component of Dance Movement Therapy. Based on the fact that the mind, the body, the emotional state and relationships are interrelated, body movement simultaneously provides the means

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Arts therapies: definitions, developments   of assessment and the mode of intervention for dance movement therapy. (EADMT Ethical Code, 2010)

An often-stated notion is that the ‘inner world’ of the client is expressed through dance and movement, and that material that might be difficult to encounter verbally becomes available through dance. The therapy space becomes one where these areas can be discovered, expressed and worked with. This is often accompanied by the idea that aspects of the client’s experiences or identity that have become ‘split’ or ‘buried’ can become integrated. For example, the American Dance Therapy Association (ADTA) reflects this: ‘the psychotherapeutic use of movement as a process which furthers the emotional, cognitive, social and physical integration of the individual’ (ADTA website). These definitions, then, are rooted in the idea that through movement and dance, the client’s inner emotional world becomes tangible and open to relationship. Authors such as Dokter (2016) and Chang (2015) have noted that the meanings ascribed to the relationships between ‘dance’ and to what is referred to as ‘therapy’ within some countries are diverse and culture specific. Jawole Willa Jo Zollar of the Urban Bush Women has linked improvisation, dance and African and African-derived music as an inspiration for her work with adults and children, particularly with black women. She says that ‘improvisation can be empowering to those who have been disenfranchised, for it can teach people how to be independent’ and ‘to move through situations, to structure a path’ (Zollar, 1994: 343; 2015). MacLow has similar concerns. She says that ‘If you dance, your body is your instrument and you intuit connections between mind and body. Improvisation communicates that most eloquently, because everything about you is reacting immediately to the situation at hand. And you can push the limits of your physical body. That’s important for people to do or see’ (MacLow, 1994: 345). These understandings of the way dance, improvisation, change and the self relate are at the heart of much dance movement therapy practice. Some dance movement therapists stress the importance of creating an atmosphere of safety and security, as this is seen as enhancing the clients’ use of improvised movement. Often the sessions follow a pattern of initial warm-up led by the therapist, a section where material is explored through movement, and a reflection period and closure. This might involve a theme selected by the client, together with the therapist, or might link back to material from previous work. As with other arts therapies, it might be directive or non-directive, and there may be verbal reflection within the session. In DMT particular importance is given to the embodied relationship, often connected to the work of Chace (Chaiklin and Schmais, 1986). Recent enquiry explores the development of understandings of the nature and impact of DMT from the perspective of reviews concerning its efficacy in relation to people living with depression (Meekums et al., 2015), schizophrenia (Ren and Xia, 2013) and dementia (Karkou and Meekums, 2017).



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Aims of dance movement therapy The UK Association for Dance Movement Therapy (ADMT), when describing the potential benefts of dance movement therapy, focuses upon different kinds of connection. These include DMT’s capacity to enable links between thought, feelings and actions, inner and outer reality, physical, emotional and/or cognitive shifts. There is also an emphasis on DMT’s capacity to expand or develop the client’s potential in ‘increasing self-awareness, self-esteem and personal autonomy’, or maximising an individual’s capacity for communication or social interaction. Reality testing and learning or re-learning in a safe environment also feature. Examples of this include increasing and rehearsing adaptive coping behaviours; expressing and managing overwhelming thoughts and behaviours; testing the ‘impact’ of self on others; and developing trusting relationships (ADMT website, 2017). Stanton-Jones, in her work with outpatients in a psychiatric ward, speaks of the aims of DMT in this way: • • •

To activate and motivate patients to use movement as a means with which to experience new ways of interacting with others To explore imagery emerging from and through the movement To extend the patient’s expressive range of movement in planes, shapes and qualities. (Stanton-Jones, 1992: 126)

She underpins these aims with the assumption that the imagery emerging from movement can be interpreted as evidence of unconscious processes within the group and ‘the communication contained within the quality of movement can be reflected back to the clients by the therapist’ (StantonJones, 1992: 126). Other approaches and goals reflect physical and emotional change. The US Administration on Aging, Department of Health and Human Services gave a research grant, for example, looking at DMT work with older individuals who have sustained neurological insult. The findings of the study framed change in terms of the functional abilities of individuals – these included balance, rhythmic discrimination, mood, social interaction and increased energy levels (ADTA website). In group work in a setting for clients with mental health problems UK dance movement therapist Steiner talks about DMT and its aims in a similar way. She allies her work to jazz: ‘The beginning and the end are fixed, all the rest is improvisation. Everyone gets a chance for a solo whilst being supported by the rest of the band’ (Steiner, 1992: 150). Themes emerge from warm-ups or discussion, and then a focus may emerge that reflects a group theme, or relates to an individual. She says that these often take the form of images that ‘arise from the pooled group unconscious, triggered off by the common group activity’. The group exploration aims to recognise and acknowledge these, to understand them and to become more aware of these ‘unconscious forces’, and to develop mutual support (Steiner, 1992: 150).

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She illustrates this process: a group of seven psychotic or borderline residents, ‘at various stages on the continuum between sanity, coping, and breakdown’ (Steiner, 1992: 161), meet weekly for one-and-a-half hours: When Jeremy complained of obsessive thoughts, which prevented him from stopping talking, I asked him to translate them into movements. His response was a crescendo of fists, shaking violently, and kicking movements. So he found ways of physical outlet for his nervous mental energy and was eventually able to contact some of the depression that was underneath his anger. Then he could even allow the group to hold him in the middle of the circle and rock him soothingly. (Steiner, 1992: 158–9) Movement is seen here as the vehicle for creating a structure to hold the powerful projections of the clients and the fear of further breakdown. Movement aided the process of grounding and centring, and opened possibilities for symbolic expression, communication and interaction. Some forms of DMT, such as those above, use verbal analysis, interpretation and reflection. Other forms focus on movement without the therapist offering such analysis, with the therapist at most only making a verbal acknowledgement of the movement made. In discussing her work in a special school for pupils with emotional and behavioural difficulties, Payne deliberately practises in this way: ‘there is no attempt at interpretation of the child’s feelings or thoughts but an active focus on the movement material presented’ (Payne, 1992: 63). This intends to convey a recognition and acceptance of what is going on, to support interaction and to encourage the child to talk. The aims are to promote differentiation of experiences, and information processing – these are seen as especially important for children with ‘chaotic thinking’. In dance movement therapy the therapist often moves with, and can be physically engaged with, the client. Payne says that through such physical engagement and movement the therapist is able to influence the form and expression in the direction of therapeutic aims. She can also model possibilities in movement, can open a path to communication at a preverbal level, and can encourage the client in movement by showing what is possible. These examples show the variety of ways in which the use of creative movement and dance in a therapeutic relationship can work to meet the needs of different client groups. Different aspects of movement and dance are used to explore and resolve client issues, emphasising the relationship between the physical and the emotional, the body and psyche.

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Between the arts therapies

Introduction: differences and similarities One of the debates within the arts therapies has concerned whether the art forms and processes should be divided into separate services and professions with distinct identities and ways of working, or whether there should be one discipline which makes use of a variety of art forms and processes. There is a long tradition within different cultures of forms that combine the arts. Massey and Massey say that ‘Bharata, the father of Indian aesthetics, saw all artistic forms as expressions of the same creative urge’ (1987: 115), pointing out that in Bharata’s writing drama, music and dance were employed together as a matter of course. In early Hindu plays music, poetry, dance and costume ‘were equal members of the same body’. They point out how ingrained in culture this is, linking it to the wide appeal of Indian flm. Others have pointed to the fact that children do not naturally differentiate between expressive forms and that, especially in arts therapies work with child clients, such division does not suit the expressive language of many children in different cultures. We can see this refected in writing such as Matthews’s study of children’s early representation and the ways children construct meaning: the forming and transforming nature of art materials has great facilities for representing . . . events, but the child employs many other materials and activities to consolidate these understandings. Emerging conceptual understandings are ‘transported’ . . . from one medium to another. From enacting, for example, the motion of cars, aeroplanes and people . . . running in circles in the playground, synchronising these movements with agonistic facial expressions and noisy vocalisations, the child may go on to enact these trajectories in drawing and so map them into 2D. (Matthews, 1986: 13) Research such as that of Harrop-Allin into children’s play in Soweto found complexity as individuals and groups did not separate or differentiate 59

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activities, for example between dance or music making. She sees children engaging simultaneously with ‘loxion kultcha: a conglomeration of slang and gestural languages, visual styles, township music, and dance . . . Integral to loxion kultcha is its unique communicative, expressive, and artistic practices: the “slang” and gestural language of scamto, kwaito, hip-hop, and South Africa’s brand of house music’ (2017: 29). She concludes from her observations that ‘on streets and school playgrounds, children integrate elements that epitomize young urban township culture into their musical play (2017: 29). The language of the adult researcher is stretched in terms such as ‘musical play’ as she tries to capture the synthesis and absence of division in the available cultural language that ‘normally’ differentiates between art forms and modes of expression. Arguments about the use of a framework that focuses upon a single art form such as ‘art therapy’ or ‘music therapy’ compared to ‘expressive arts therapies’ tend to revolve around such debates about the nature of the arts, cultural differences, and how these connect to the relationships between the art form and therapy in the arts therapies. Art, music, drama and dance within many traditions of education and practice are often separated in a number of ways. Examples of this separateness can be seen in the way identities are formed – actress, musician or painter, for example, or in the way subjects are taught from early education to university level. There are arts practitioners who work in a manner that does not recognise this separation, or who work in disciplines that do not separate out forms in this way. Examples of this are disciplines such as installation or the video and performance art of Mame-Dianna Niang in Contemporary African Photography and Video Art (2019) or Bill Viola (2002). However, one of the main traditions that the arts therapies has drawn on to date is one that separates each art form through training, methods, processes and professional identity. These are seen to be specific to the art form and are separate from one another. There are examples of arts therapists within this tradition using aspects of the arts outside their own ‘domain’. This tends to involve using a part of the language of another art and drawing it into their own art form. For example, a dance movement therapist would use music but this would be to facilitate movement process through rhythm, or to use sound as an inspiration to promote the clients’ dance improvisation. A dramatherapist might ask a client to produce images, but this would normally be as a part of drama: to create access to dramatic form, perhaps using the images as cues. Arts therapies that work in this way are extant throughout the world. Hyun Kim (2016), for example, discusses this separation of identity in practice and training in South Korea, whilst the Health Professions Council, which regulates training in the UK, also involves distinct demarcation and separation. This has a knock-on effect for the client. Arts therapies that operate in this way give the client access to only one art form in their sessions. Arts therapists of one discipline would not be seen to be qualified to work with



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other arts processes as a primary method in their work, nor would most arts therapists consider themselves able to facilitate other art forms in this way. Art therapists, for example, would not consider themselves able to facilitate music therapy assessment processes within their sessions. Another issue connected to the separation into different arts modalities within the arts therapies concerns cultural difference. As mentioned earlier, for some cultures the arts tend to have evolved in a way that has involved certain expressive forms such as the theatre play, painting, sculpture, ballet or dance. These tend to be replicated in forms of practice and the identity of practitioners who create them. However, there are many examples of practice and practitioner identity that work with a combination of art forms, or that do not recognise such division. In addition, not all cultures replicate this division, and in multicultural societies such separation cannot be said to accurately reflect the experiences and cultural lives of the diversity of people within such a society. Hence, people whose culture does not recognise the division may find the separation of the arts restrictive, alien and even racist in its assumptions. Here some would say power-based issues arise when the therapist holds the framework of the language and form of the arts tradition, for example, and the client is expected to adhere to this. Looked at in this way, the arts therapist’s sense of professional identity and artistic values and training does not deem them equipped to respond to cultural forms that do not replicate their cultural division of artistic experience into art, music, drama and dance movement. It’s interesting that some of the early developers of arts therapies showed an awareness of the therapeutic potentials of art forms other than the one they specialised in, and also of mutuality. In 2001 music therapist Warwick was interviewed by Simmons about her early experiences in New Zealand and about how she came to music therapy (see box). She had initially trained to be a teacher at Auckland Training College.

Auriel Warwick and music therapy MS: AW:

Had you heard of music therapy in New Zealand? No, I hadn’t. But I had had an experience when I was teaching, when I had no piano to practise on and needed creative outlet. I turned to drama and theatre. We had a very fne amateur theatre in the city . . . and the wife of the resident professional producer had been an actress with the Bristol Old Vic Company in England . . . I found her method of working (which was to start with complete relaxation of the body to music before going into vocal exercises) so incredibly refreshing. After one particularly bad day I went to her to try to cry off the session but she wouldn’t let me. After that hour I felt so refreshed that I said to her, ‘Why isn’t this done with people with psychiatric problems?’ and she

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smiled wisely and said, ‘When you get to England you will probably fnd that it is.’ So, in a sense, it was perhaps the concept of dramatherapy, but with the use of music, that planted the germ of the idea. But it certainly wasn’t conscious at that stage. (Simmons, 2001: 44)

Some, such as Petzold and Ilse (1990) or McNiff (1992), have continued this awareness of mutuality, and have argued for an integrative approach where arts therapists work with all art forms depending on the client’s needs. They argue that the individual arts therapies such as art therapy or music therapy do not constitute approaches in their own right, but are only methods (Petzold and Ilse, 1990). Arts therapists might see what they do as a dialogue – they follow the way the client expresses themselves, or indicate interest – but many would see themselves as not professionally able to follow into certain areas of artistic creativity or expression. However, some who argue against this separation practise in a way that is directly different from the those dividing into ‘art therapy’ or ‘music therapy’. Levine and Levine, for example, describe such an orientation: ‘Expressive arts therapy is grounded not in particular techniques or media but in the capacity of the arts to respond to human suffering.’ The expressive arts therapist must have an ability to use ‘appropriate media for therapeutic purposes’ (1999: 11). Arts therapists who use a variety of art forms within their work tend to see the role of the arts as being interconnected, and to emphasise the importance of creativity as primary within the process, overriding the division into separate arts disciplines. Some work brings together a fascinating mix of activities reflecting local needs and resources. For example, Danev talks of the ‘Library Project’ in work with children, supporting them after the impact of the war in Croatia (1991–5). This used the library building as a cultural and therapeutic resource for children, initially in Zagreb. It was called ‘Step by Step to Recovery’ and described as ‘an expressive [art therapy] intervention technique offered through a multimedia programme of creative activities’ (Danev, 1998: 133). The initiative was designed to be adapted in several locations in Croatia, using whatever resources were available: ‘the multi-media combination of creative techniques and materials, depending . . . on the equipment available and the abilities of the local project leader . . . painting, bibliotherapy, music therapy, video therapy, movement therapy (non-verbal), and selected computer games . . . as therapeutic media’ (Danev, 1998: 135). This description illustrates the issue, described earlier, of how the division of the arts can be seen as a cultural imposition. You can feel Danev’s language struggling here in finding words to describe the different segments of the whole that she and her colleagues and the children involved were creating! Others, such as Mertens (1996) and Herrmann (2000), have argued against the



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notion of an integrative arts therapies approach or profession. Herrmann, for example, says that ‘As far as merging all the arts therapies into one profession . . . [it] is doomed to lose the expertise that each form of art in therapy requires’ (Herrmann, 2000: 27).

How different is different? How similar is similar? Wigram raises the issue of referral, saying that it is common in many countries for professionals from other disciplines to be unaware of why they should refer someone to music therapy. Such comments are equally relevant in relation to client self-referral. Looked at in this way, it is important to have referral criteria that communicate clearly to people who are not familiar with the arts therapies. He gives an example of referral criteria developed from his work with people with autism: • • • • • • • • • •

Difficulties with social interaction at verbal and non-verbal level Lack of understanding or motivation for communication Rigid and repetitive patterns of activity and play Poor relationships Hypersensitivity to sounds Lack of ability or interest in sharing experiences Significant difficulties in coping with change Apparent lack of ability to learn from experiences Lack of emotional reciprocity and empathy Poor sense of self. (Wigram, 2002)

Such referral criteria attempt to reflect a service’s experience of the needs of the person likely to attend the setting, and to anticipate why they might come to an arts therapy such as music therapy. In addition, the criteria contain a basic notion of the areas likely to be featured in the music therapy in terms of expression, development and change. Wigram (2002) follows referral by an initial assessment period, and a period of work to identify the needs of the client and the direction of the therapy. What is interesting to me is that the way in which the referral criteria described above could easily relate across the arts therapies: to art, drama, movement or music. Wigram then creates a series of five areas of ‘expectation’ that the therapy might look at. These are: developing communication, developing social interaction, meeting emotional needs, cognitive development and ‘areas of therapy specific to autism’. I want to examine two of these areas in some detail, to look at what is common to all the arts therapies and what is specific to music therapy. These two areas are the development of communication, and the ‘areas of therapy specific to autism’. Development of communication is subdivided by Wigram into five points – activating intersubjective behaviours, spontaneous initiation of contact, development of meaningful gestures and signs, development of

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communicative vocalisation and emergence of language in song. Areas of therapy specific to autism are described as the tolerance of sounds, meaningful use of objects – from stereotyped and unimaginative use of part-objects, and seeking to divert clients away from habitual, stereotyped, ritualistic, perseverative or obsessive behaviours (Wigram, 2002: 15). This way of looking at therapy is oriented towards considering how change can occur from a behaviourally oriented framework, concerning aspects of ‘physical, social and emotional behaviour’ (Wigram, 2002: 14). The definition of these two areas of referral and the expectations of therapy are interesting in that they could be seen to be the same or similar for dance movement, drama or art therapy practising within such a framework: they do not refer to specific elements of the arts process within the particular arts modality. Some of the areas of expectation, though, are oriented specifically towards music. In ‘Developing communication’, for example ‘language in song’, and in ‘Areas of therapy specific to autism’, ‘tolerance of sounds’ seem to be unique to music. Even here, though, the second example concerning ‘tolerating sound’ could be seen as relevant to the other arts therapies in terms of speech, or the sound of music and instruments, or vocalisation in drama or dance movement therapy. The rest of the expectations of the therapy and the referral could be seen as just as appropriate for all the arts therapies. Wigram goes on to describe events within a therapy session based on these areas and expectations. He talks about the responses and interactions between himself and an individual client diagnosed as autistic. He analyses in detail an assessment session designed to help ascertain whether music therapy can help. He describes this as aiming to build up a picture of the client’s strengths and needs in order to be as clear as possible, ‘as to the precise nature and severity of his social and communication impairment’ (Wigram, 2002: 14). The assessment includes a variety of activities. At the start of the session therapist and client together improvise a piano duet. Wigram notes that the client matches his own tempo and rhythm, and also moderates tempo and volume, at times taking over the melody. This is followed by a drum duet, drums and piano playing together, dropping drumsticks on the drum, copying rhythmic patterns, singing together with instruments, with the therapist using a microphone, and the client making up his own words in solo singing, and saying and singing hello. There is a game of pretending to go to sleep, waking up and having breakfast, where the therapist models exclaiming ‘Ugghh’ when eating his drumstick, along with sharing a drink of imaginary tea. Here, apart from the last game, the therapy is clearly rooted and primarily articulated in music. Wigram links each event to the music therapy ‘expectations’ and ‘referral areas’ as described earlier. So, for example, the client singing and saying ‘hello’ is connected to the development of communication. Activities are seen as examples of spontaneous initiation of contact, intersubjective behaviour and the development of communicative vocalisation. Wigram brings his own musical artistry and his knowledge of how music can be facilitated for another to the process and relationship by his piano playing, work with rhythm and singing.



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So, whilst the areas of referral and the expectations of therapy could be common to all the arts therapies, the description of the events or activities within the therapy, and the response and interaction between client, therapist and art form are seen by Wigram to be clearly in the language and process of music. This is an important point, and one that can be seen across much of the practice analysed and described in this book. It is possible to argue that the broad aims and directions of therapy, along with its general outcomes, are largely common to all the arts therapies. It is in the language and the interactions within the therapy itself that the differences fully emerge. What the arts therapies have in common is their aims, and broad benefits to be brought: it is in the particular, the specifics of form and interactions of the individual sessions, that the differences of identity, language and process emerge. The importance of this analysis is that it creates a framework from which to see commonality and difference. In the broad understanding of change, in the assumptions about what enables change to occur, and in the broad views about what change is and how it happens, the arts therapies have much in common. In the language and process of specific sessions we have some areas of commonality, but it is here that the differences emerge: in the languages that realise these broad aims and understanding of change, in the processes that create response and interaction between clients and therapist.

Arts therapies and arts in health It’s important to differentiate between arts practised in health settings and the arts therapies. Arts in health settings tend to be devoted to two main areas. The frst is creating access for those who have been disenfranchised from participating in the arts, whether as makers or consumers. The second area is where the arts are practised in ways that complement health practice concerning the commissioning of art in hospitals, or the use of the arts in health promotion. Initiatives in these areas have occurred at local, national and international levels. On a local level, for example, the ‘Good Medicine’ report in the early 1990s looked at arts in health initiatives practised in the West Midlands region of Britain. It concluded that managers of hospitals and healthcare settings had a growing awareness of the ways in which the arts could be of great benefit to the health sector. The focus is on improving healthcare environments, for example by making them more ‘friendly or interesting’ and involving the local community in arts that are ‘socially relevant’ (Roberts and Bund, 1993: 2). It notes that participatory arts run by professional artists have a different purpose from arts therapies though they can have an indirect therapeutic effect: There are radical changes taking place in the way in which the medical profession views its role with a growing emphasis on prevention. The arts already play a big part

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Arts therapies: definitions, developments   in this process of change . . . Health promotion clinics are now an everyday part of the work of most GP practices. Developmental arts in health work are taking place in the primary sector in the region. (Roberts and Bund, 1993: 13)

It cites as examples theatre in education projects raising awareness about HIV and Aids, and substance abuse. In 2009 a parallel position is reflected in the ‘first international Latin American arts and health forum’ which took place in Peru, in which partners developed a ‘visionary statement’, entitled The Lima Declaration on Arts as a Bridge to Health and Social Development (Pan-American Health Organisation, 2009: 1). Parkinson and White describe it as embracing the ‘whole Latin American continent’ and as fuelled by a ‘vision of the arts as a powerful force for social change, addressing health and economic inequalities’ (2013: 183). They also cite work in Finland as an exemplar of arts and health work with a vision of how ‘health and well-being can be promoted by means of art and culture’, arguing that art and culture ‘can enhance inclusion at the individual, community and societal levels; and everybody should have the right to participate in, and enjoy, the cultural life of the community’ (2013: 185). The relationships between arts and health and the arts therapies has been much discussed, concerning issues such as parallels and differences between them. Learmonth and Huckvale, for example, identify a parallel in that ‘arts interventions are part of a broadening of our vision of health and treatment to a more all embracing one’ (2009: 1). Roberts and Bund identify differences concerning intention and effect: Arts workshops are run by professional practising artists and are not intended, in any way, to be used in a clinical context for direct diagnostic or treatment purposes. They are not to be confused with the work of the professional arts therapist; nor the work more closely associated with Occupational Therapists and a programme of diversional therapy. The purpose of the participatory arts is to bring fun, enjoyment, involvement and an opportunity to find a means of self-expression and discovery: all this may contribute to a beneficial, therapeutic effect. It is not, however, therapy in the clinically defined sense of the word. (Roberts and Bund, 1993: 28) Senior and Croall, reflect this position, seeing the scope for the arts therapies as involving direct therapeutic work as part of the clinical provision, whilst arts activities create ‘access to the arts for thousands of people who would not otherwise have the opportunity to be involved, whether as audience or participants’ (1993: 7). I would concur with Senior and Croall (1993) who note the potential for cooperation between arts practitioners



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in health contexts and arts therapists. They recognise the two areas as different but complementary.

Professional identity In a number of countries, as described earlier in Part II, arts therapies associations have come into existence to develop relations between training institutions, clinical settings and legislative or regulatory bodies concerning educational, professional and ethical standards for members and practice. The Canadian Art Therapy Association (CATA) was formed in 1977, for example, and sees as one of its key objectives ‘to promote and maintain national standards of training, practice and professional registration’ (CATA website). Another example, from the same era, is refected in psychiatrists founding the Korean Clinical Art Association in 1982, as ‘a subordinate organization of the psychiatric community of South Korea (including music, painting and dancing). This marked the beginning of the therapies using art activities’ followed by, in 2005, ‘many doctors, dentists, oriental medicine practitioners, counsellors, artists, social workers, as well as experts and leading academic fgures joining forces and establishing the Korean Academy of Clinical Art Therapy (KACAT)’ (Hyun Kim, 2016: 9). Associations promote the arts therapies through information and research, and lobby or make representations to statutory and governmental bodies regarding recognition and provision. They also often oversee requirements that must be met to enable individuals to qualify and practise as arts therapists. Each association or organisation tends to have an approval and monitoring process, a code of ethics and standards of clinical practice often including a role for overseeing and regulating clinical supervision and professional development. The nature of such associations and organisations varies across countries. Many associations focus on specific disciplines, such as dance or art, others work across disciplines creating coalitions. The Japanese Music Therapy Association (JMTA) was established in 2001, for example. The National Association for Drama Therapy (NADT), as another example, was formed in 1979 in the USA and is also a member organisation of the National Coalition of Creative Arts Therapies Associations (NCCATA) aligned with art, music, dance and poetry therapies. International coalitions include the World Alliance for Dance Movement Therapy (WADMT). Another international collaboration is the European Consortium of Arts Therapies Educators (Ecarte), which was developed in the 1980s to encourage communication and knowledge exchange between member states. In the USA Art Therapy Registration (ATR) is granted upon completion of graduate education and postgraduate supervised experience. Board Certification (ATR-BC) is granted to registered art therapists who pass a written examination, and is maintained through continuing education. Some states regulate the practice of art therapy and in other states art therapists can become licensed as counsellors or mental health therapists. In the UK, in 1980 the Department for Health and Social Services (DHSS)

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recognised that no one could be employed as an art therapist without having completed a recognised postgraduate course. In 1997 state registration in the UK was granted for music, art and dramatherapists under the Council for Professions Supplementary to Medicine (subsequently titled the Health and Care Professions Council: HCPC). This meant that only music, art or dramatherapists registered with the HCPC could legally practise. Attached to this is a range of requirements including training and ethical and professional standards. The following extracts offer the headings of much more detailed areas within the standards. It chooses to engage with the arts therapies in a particular manner: by creating areas which are identified as commonalities and others which are situated as particular to each discipline. The headings for commonality are given as a series of statements, for example: Registrant arts therapists must: 1 be able to practise safely and effectively within their scope of practice 2 be able to practise within the legal and ethical boundaries of their profession 3 be able to maintain fitness to practise 4 be able to practise as an autonomous professional, exercising their own professional judgement 5 be aware of the impact of culture, equality and diversity on practice 6 be able to practise in a non-discriminatory manner 7 understand the importance of and be able to maintain confidentiality 8 be able to communicate effectively 9 be able to work appropriately with others 10 be able to maintain records appropriately 11 be able to reflect on and review practice 12 be able to assure the quality of their practice 13 understand the key concepts of the knowledge base relevant to their profession. (HCPC, 2018) Another section differentiates according to each profession. The following offers a sample of these: Art therapists only: understand that while art therapy has a number of frames of reference, they must adopt a coherent approach to their therapy, including the relationship between theory, research and practice and the relevant aspects of connected disciplines including visual arts, aesthetics, anthropology, psychology, psychiatry, sociology, psychotherapy and medicine. Dramatherapists only: understand core processes and forms of creativity, movement, play and dramatic representation pertinent to practice with a range of service user groups understand both the symbolic value and intent inherent in drama as an art form, and with more explicit forms of enactment and re-enactment of imagined or lived experience.



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Music therapists only: understand the practice and principles of musical improvisation as an interactive, communicative and relational process, including the psychological significance and effect of shared music making. (HCPC, 2018) The standards illustrate a particular framework for considering the relationship between the arts therapies in terms of commonality and difference. This reflects the debates and positions outlined earlier in this chapter, concerning the broad aims of the arts therapies often being relatively parallel, whilst the differences lie in the detail of practice. However, it takes a particular position on this where the non-arts elements of professional practice are seen as common and areas concerning arts elements of the profession are located in the separate professions. So, the common headings reflect broad aims concerning being able to ‘communicate effectively’ or to ‘work appropriately’, but do not feature commonalities in terms of creativity or a capacity to improvise or facilitate artistic expression for others. These are positioned within the sections which refer to the individual arts therapy ‘only’. This illustrates the ways in which the creation of such standards are not neutral, but reflect a particular position. Here, as my analysis shows, is a position that does not situate creativity and arts facilitation as commonalities across the different professions, something this book has argued is a key, defining commonality. This standardisation and professionalisation is by no means the norm. In countries where the arts therapies are less established, associations may not exist, or may be in the early stages of development. In this situation relationships with other professional associations may be sought. This illustrates that the patterns of registration and monitoring of arts therapist practitioners varies widely, with different countries evolving different routes towards establishing standards and professionalisation. The processes of standardisation, approval and professionalisation in the arts therapies have passed impressive milestones in the past halfcentury in a number of countries. However, in some countries more remains to be done to develop the full professional potential and recognition of the disciplines.

Conclusion: from definition to exploration At the start of Part II I said that the defnitions were pictures that would give us information. Each chapter has looked at the pictures given by a different modality. There are many parallels between art, music, drama and dance movement arts therapies, both in terms of process and aims, and even of language. There are undoubtedly differences, but, in the pictures the defnitions enabled us to begin to see, there are common themes that will be present in the next chapters in this book. These include the particular ways in which arts media and processes within the arts therapies allow

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clients to communicate, the effect the art form has upon the therapeutic relationship, and the particular ways in which arts languages and processes allow clients to explore and develop the material they bring to the therapeutic space. Read Johnson says that the arts therapies ‘have not developed in the mid twentieth century by accident. They are the result of historical processes, and serve some function for our culture now and in the future. We must understand that function and find a way to articulate it meaningfully’ (1999: 72). In Part III we will begin to look at some of the ways in which these areas started to make links. This will serve to begin to explore how the processes of the arts and therapy came together to form a new, powerful tool for change.

PART III

Backgrounds, histories and encounters: from the first happening to the shadow of logic in africa, music healing or music therapy exists. they have a common historical tradition and application. it is closely knitted with religious practices. this is why one can easily see the different shades of african music performing healing functions. interview with aluede, from chapter 8, page 79

eight

from the frst happening

Introduction: different histories pocock (2005) and schwartz and colman (1988) argue that disciplines or professions do not usually develop in one simple linear way over time, and that it is unlikely that those researching the origins of a profession, for example, ‘can prove that one event or idea “caused” the profession to develop as it did’ (1988: 242). my approach will be to follow their suggestion that examining accounts and sources is useful in understanding both the nature of historical development, and also in situating and examining ‘sets of ideas’ to create dialogue between past and present in order to ‘contribute to the profession’s evolution’ (1988: 242). Johnson articulates well the need for dramatherapy, for example, to understand how it is ‘the result of historical processes’ in understanding the feld’s ‘function’ and ‘to articulate it meaningfully’ (1999: 27). this chapter and chapter 9 use these ideas about historical perspectives to help understand the infuences on the development and identities of practising therapists and of understanding the values of the arts therapies to people who access them. as we will see, these histories are allied to issues of culture, power and ownership. despite some western accounts that assume a single narrative, usually claiming the origin in the author’s country such as the usa or england, there is no evidence that there is a single history. initially such accounts consisted of personal narratives of those deemed to have ‘founded’ the arts therapies, though recent work has adopted a more communal, analytic rather than descriptive approach. there are a number of different versions: histories of the arts therapies. many accounts of the origins of the arts therapies draw on two kinds of history. the first is seen as an ancient lineage, linking healing and the arts through processes such as ritual or a tradition of healers, rather like the one quoted from this chapter at the start of part iii (mcniff, 1992; landy, 2001). the other concerns the emergence in the twentieth century of the professions and practice of the arts therapies within contemporary health and care-related settings such as hospitals, schools and private practice. such an approach has been used in relation to different countries and continents: from europe (nöcker-ribaupierre, 2015) to africa (myers, 2015). the irish association of creative arts therapists (iacat) puts this history 72



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in a multicultural context of the healing ‘virtues’ of arts activities. it relates the origins of the arts therapies to accounts of visions and dreams, and to art objects linked to shamanic ritual or healing practices. this is often echoed by a number of authors and in various accounts, though interpreted in different ways. the american music therapy association (amta), for example, says the notion that music is a healing influence that can impact on health and behaviour is ‘at least’ as old as the writings of plato and aristotle. sanivarapu’s history of music therapy in india analyses literature on the ‘science of music (Gandharva tattva)’ dating back to the fourth century Bc (sambamurthy, 1999), referring to Raga Chikitsa as ‘one of the ancient texts’ that ‘elaborates on the therapeutic role of musical melodies’ and to swami haridas, ‘a classical musician who lived in the sixteenth century, as one of the many who used music in treating illnesses’ (sanivarapu, 2015: 210). walker’s research acknowledges parallels across different cultures: a belief common to practically all cultures appears to be that concerning the power of musical sound to exert some influence over our physical and mental states. a ubiquitous version of this is the belief in the power of songs to heal physical and mental sickness; equally pervasive is the belief that certain sounds are inextricably linked in some way to the character, or ethos, of an object, person, tribe, nation or other group of people. (Walker, 1990: 180) the idea that artistic activity and exposure to art forms are intrinsically beneficial is not accepted by all. the idea that the arts can harm as well as heal has been expressed. hamm cites a psychiatrist who says that rock and roll is a ‘communicable disease’ (1979: 180). in 1961 a classical cellist, for example, described rock and roll as ‘a poison put to sound – a raucous distillation of the ugliness of our times . . . it is against art, against life. it leads away from the exultation and elevation of spirit that should naturally spring from all good music’ (in hamm, 1979: 400). Jazz in the 1920s was seen by some as ‘doing a vast amount of harm to young minds and bodies not yet developed’: it was ‘an activity which may be analysed as a combination of nervousness, lawlessness, primitive and savage animalism and lasciviousness’ (merriam, 1964: 242, in walker, 1990: 181). however, the potentials in the arts for healing are seen across cultures and across historical periods. this background is often referred to in linking current practices named as ‘arts therapies’, initially developed as terms and as professions during the twentieth century, and practices which may not use the same terminology within other cultural contexts or historical periods. though, as these chapters will show, other ways of analysing the relationships between the arts and healing contest this way of looking at history (aluede, 2006; Bogen, 2016; solomon, 2005). a common perception is that the connection between the arts and healthcare was diminished in many cultures, especially in western medicine, until

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its revival or rediscovery in the twentieth century. a major review of the arts and healthcare in the uk funded by the calouste gulbenkian foundation says, for example: ‘in many cultures the connection between the arts and healthcare has been a strong one in the past. in more recent times it has been largely lost sight of’ (senior and croall, 1993: 3). the irish association’s account similarly refers to a ‘re-emergence’, as a ‘rich melting pot of influences came together, and art therapy emerged as a way of focusing this power in modern psychological healing methods’. they include in this ‘melting pot’ the development of child-centred approaches in education which emphasised the importance of each individual’s unique potential and creativity, interests in the art work of people with mental health problems and in particular: the many modern art movements; expressionism, surrealism and symbolism [which] were concerned with the subjective, rather than objective experience. the burgeoning psychoanalytic movement was generating new insights into human motivation and behaviour, and new models of the psyche. (IACAT website (art therapy)) the amta account also supports this idea of a re-emergence, saying that the impetus behind the twentieth-century discipline began after the two world wars when community musicians went to veterans’ hospitals to play for people, including those suffering emotional and physical trauma from the conflicts. the responses led to musicians being hired by hospitals, developing a need for training. one of the earliest music therapy training degree programmes in the world was founded at michigan state university in 1944. the first widely circulated documented uses of the term ‘dramatherapy’ also occurs in a paper written around this time by peter slade for the British medical association in 1939 (Jones, 2007: 44, 82). casson (2000) and Jones (1996) trace dramatherapy’s origins within the literature. Jones discusses origins broadly, examining wider historical trends from early societies (1996: 43–6), through to more recent developments in many countries from the eighteenth century onwards (1996: 46–5), referring to documented practice since the 1930s and tracing the emergence of practices and terminology (1996: 71–95). this included the emergence of work in Jamaica, the first attention within the dramatherapy literature of reil’s nineteenth-century work in asylum theatres (Jones, 1996: 47) and russian evreinov’s early twentieth-century theatrotherapy (1996: 54–7). such an approach draws on literature to evidence history rather than relying only on personal accounts. secondly, it connects dramatherapy to practice and theory existing outside of england and the usa in the 1950s and 1960s. it also begins to theorise the history of dramatherapy. rather than offering a narrative account only, it develops a theoretical analysis of the development of the arts therapies. Jones creates a developmental understanding based on a review of literature and on interview, conceptualised into three stages. the



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first involves drama or theatre undertaken in clinical or ‘special educational’ contexts with an emphasis on creativity and entertainment or recreation (2007: 46–7). the second phase is typified by accounts and understandings involving drama positioned as ‘an adjunct to therapeutic processes’, needing ‘the context of another “accepted” form of therapy to be effective or safe’ such as verbal psychotherapy or occupational therapy (2007: 48). the third is conceptualised as asserting drama as ‘the primary medium of change and as a therapy in its own right’ (2007: 48). Johnson, emunah and lewis (2009) also position history and interdisciplinarity within a valuable theorised frame. they argue that ‘our reliance upon other fields for our foundations has been of some concern to creative arts therapy scholars, who on the whole have expressed strong desire for independent theories for our disciplines’ (2009: 17) citing Jones’s position that, ‘too often in the past theorists and practitioners have had to look outside dramatherapy itself to try to justify its relationship to change, to “find clothing which is made up of items from others wardrobes”’ (Jones 1996: 29, cited in Johnson et al., 2009: 17) and landy’s argument that the field needed ‘to discover a new or comprehensive model which reflects the creative, expressive nature of drama therapy’ (landy, 1994: 44). other accounts challenge this conceptual framework of loss and reemergence, arguing for a history that is more accurately described as one of continuity of the relations between the arts and healing (aluede, 2006; Bogen, 2016). these are often located in countries with a strong presence of what has been termed ‘traditional healing’ or ‘traditional and faith-based healthcare systems’ (moshabele et al., 2017), such as the following research from nigeria. Bogen, for example, challenges the view of ‘many authors (who) have represented art-in-health practices as a modern western concept’ (2016: 2). she demonstrates in her review that they ‘are neither modern nor exclusively western’ and that ‘creative activities were used in ancient china to heal body and mind for more than two millennia’ (2016: 2). she creates a nuanced approach to understanding the history of relationships between ‘arts in health practices’: including ‘therapeutic practices’ defined by ‘function’ such as pain treatment, stress reduction or acceleration of recovery, of ‘educational practices’ and of ‘healing environments’ concerning the creation of settings and spaces for health (2016: 6). her review includes a consideration of what she describes as ‘art practices in the history of chinese medicine’: Yin kang shi dancing was mentioned in the chapter 音乐 篇 (ancient music part) of the book on music 吕氏春秋 (lü shi chun Qiu) by lü Buwei, 吕不韦 in 239 Bc. it was invented by the ancient clan leader Yin kang shi, 阴康氏 who belonged to Yin kang clan in shaanxi province presumably living before 4500 Bc. Yin kang shi dancing was a method to stimulate blood circulation and enhance immunity, to relieve pain and to release emotions. in particular, the exercise targeted symptoms – associated today

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Backgrounds, histories and encounters   with arthritis and rheumatism – which were presumably caused by flood disasters that frequently haunted the clan’s populated region. (Bogen, 2016: 8)

some see this ‘continuity’ over time as a creative process of development, change and exchange, whereas others see it as uneasy: connected to forces such as colonialism and of suppression by dominant discourses of medicine, healing and identity (solomon, 2005; gómez carlier and salom, 2012). accounts in these contexts are often concerned with what occurs as this continuity comes into contact with the ‘versions’ of arts and healing that have emerged in western or western-influenced health services during the twentieth century – for example, as aluede (2010) puts it, when those who have ‘studied music therapy overseas’ return to their own country. gómez carlier and salom approach this ‘contact’ in terms of acculturation and dialogue, using the term ‘art therapy’ in relation to colombia, where they situate it as involving how ‘colombians migrate to study at established international programs, bringing back professional knowledge upon their return,’ positioning their work in terms of ‘the assimilation of art therapy into the colombian culture’ (2012: 4). their reflections on practice with children, for example, talks of how ‘we observed the negative impact of importing interventions and extracting treatment issues even before knowing the children who were participating, and coming to understand their stories, their level of education, their relationship with the art materials, and their cognitive and emotional development. assumptions and preconceived ideas coloured our initial judgments’ (2012: 9). they respond to this tension by arguing that ideas about ‘mental health, mental distress, and trauma should be contextualized as they may differ from prevalent western notions’ and move toward a response to the relationship as one of ‘acculturation’: as art therapy migrates to different countries the cultural approaches to materials and processes need to be carefully revised and should include consideration of the availability and value of materials and their cultural associations. even more importantly, a search for native materials and processes that honor historic and geographic identities may increase the host culture’s impact on and contributions to art therapy. (Gómez Carlier and Salom, 2012: 9). i want to present three perspectives to illustrate the nature, variety and complexities of history and identity in the arts therapies. the first is from aluede’s (2006) research into the history of music therapy in nigeria. it offers a range of perspectives on the development and identity of the arts as healing and as therapy. the second is from the developments in postsecond world war north america at the Black mountain college, as a way



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of illustrating how the ‘climate’ for the arts therapies was emerging in some parts of the world. this setting, its atmosphere and opportunities, stands in for many other places and occasions in the twentieth century when potent mixtures of people, ideas and practices were fermenting. the third set of perspectives, in chapter 9, are from Brazil, Japan and from the uk, with a particular example from the 1960s, when the society for music therapy and remedial music’s one-day conference on music therapy met in london on 30 april 1960. it represents many other meetings in the 1950s and 1960s when the arts therapies were emerging into health provision in their own right in many parts of the world, and gives us a picture of the changes in thinking and work taking place at this time.

Focus on Research: music therapy and Nigeria Interview with Charles O. Aluede This interview is based on the research ‘Music Therapy in Traditional African Societies: Origin, Basis and Application in Nigeria’ (Aluede, 2006). aluede (2006, 2010) situates his analysis of the history and ‘emergence’ of music therapy within the complexities outlined in the previous section. he engages with the concept of ‘music therapy’, identified by him as being an influence from the usa, but also as situated within specific nigerian history and practices. in examining nigerian music therapy or, as he also calls it in his interview below, ‘music healing’, he problematises the meaning and act of making history and of definition. one aspect of his consideration of the history of music and therapy in nigeria identifies the ways in which western musicologists in the twentieth century were ‘incompetent’ in bearing witness to traditions that were oral and not based on written text that form the western ‘norm’ (2006: 31). he also notes that nineteenth- and twentieth-century accounts drawn on in academia tended to be made by ‘western travelers’ whose perceptions were affected by their viewpoint and a ‘primary economic motive’ (2006: 31). his perspective on history draws on a combination of fieldwork, observing practices and accounts of others, alongside a consideration of artefacts. his argument for a nigerian perspective on music as therapy’s history and identity, creates a reflective dialogue between terms and concepts – arguing that ‘music therapy’ is both a contemporary term and an ancient phenomenon. an example is how ‘music is . . . used as a reviving agent for a dying person or one in coma . . . a common practice generally in nigeria and the esan of edo state of nigeria in particular, herbalists and native doctors have Oko – a small aerophone made of elephant tusk which is blown into dying patients’ ears to resuscitate them’ (2006: 34). aluede talks of this in terms of cultural and societal awareness of practices which connect with the contemporary term of ‘therapy’ and which can offer understandings that interpret each other. he argues that ‘traditional african music in african societies reveals that

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music is woven around every event of the african’s life from birth through to death’ and he connects this to how ‘the curative properties of music are not just known in the religious circles alone. in the ordinary social lives of the africans this belief is held and explored’ (2006: 33). he asserts that, ‘africans are certain about the healing nature of musical sound and this idea has been in existence long before now’ (2006: 33). in your article you say that, ‘music therapy in nigeria has an ageold historical origin’ (2006: 35) and you cite lateef about nigeria: ‘lateef (1987: 199) posits that “long before the mid-1940s, when for the frst time in the usa music therapy began to be used as a specialty, music therapy was one of the major aspects of the Bori religion in nigeria”’ (2006: 33). how do you see the relationships between the different histories – the usa tradition and the nigerian? what are the positive elements of this relationship and what are the challenges for music therapists? aluede: early in time, music making was a communal activity in nigerian society, and the avenues for musical performances were collectively determined. such performances were held during bereavement periods of one’s spouse, siblings and parents and during the cleansing of the land (this could mean town, village or community). during moon-lit nights people of the same ages aggregate to sing and dance together. it is also at such times that people gather around their aged parents and grandparents to be told stories with musical preludes, interludes and postludes. aside of these avenues, music making is also concomitant with the construction or reconstruction of neighbours’ houses or destroyed houses, and when a neighbour is under the grip of illness. from the above, one could discern that music helps to strengthen individuals in times of bereavement and aid communal cleansing activities. in so doing, music is used to cleanse the land, to create an opportunity for social interaction, to educate and rehabilitate, to create room for exercise and movement skills, and to stabilise the emotions of community dwellers. through group musical activities, a kind of conscious or unconscious prophylactic treatment for participants is provided to ease tension and heal the sick among community dwellers. the scenario in america is not entirely the same as this. the history of music therapy in america is relatively recent compared to that of africa: in terms of nature, scope and competence, it is currently slim. important, too, is the fact that the current practice of music therapy is restricted in general hospitals, schools, prisons, health centres, training institutions, psychiatric facilities, private practices and universities, whereas it is boundless in africa. obviously, there is a general consensus that music is therapeutic. and that people across different climes have musical practices geared towards healing. Beyond healing, music has been acclaimed to have many more attributes. for example, levitin (2010: 50–1) claims that in africa, music is not an art form as much as it is a means of communication. singing together releases Jones:



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oxytocin, a neurochemical now known to be involved in establishing bonds of trust between people. so far, the palpable challenges of music therapists in nigeria are: the quest for an acceptable nomenclature of what music healing should be called in nigeria, and the training needs of the music therapist will be major determinants in the definition and development of the curriculum for the training of the individuals who will function in the society. Beyond the courses in theories of sound and healing, practicum in general hospitals, prison, teaching hospitals, psychiatric facilities, among others, courses in ethno-medical fields and ethno-therapy are very important because ‘biomedicine does not contain culture-free clinical realities’ (kleinman, 1978: 91). for nigerians who studied music therapy overseas, the onus is on them to fashion out the real needs of the student therapist in our country. the said real needs should embrace the cultural realities of the people the music therapist is expected to serve. human resource application demands the evolution of culturally relevant models of training. this aim has become very germane because of the palpable lapses/differences in western/african ideas of disease causation if put side by side. to conclude this segment, the observation of daniélou is very informative. he asserts that: almost the whole of western terminology in africa, almost the approaches, whether the intention behind them was good or evil, almost all the efforts made to take an interest in african countries so as to “help” them in their “development”, have in many fields completely ignored or by passed the historical and cultural realities. (1972: 52) how do you see the history and tradition of music as therapy or healing in nigeria in relation to other countries in africa? aluede: in africa, music healing or music therapy exists. they have a common historical tradition and application. it is closely knitted with religious practices. this is why one can easily see the different shades of african music performing healing functions. Just as african music is a confuence of many arts, so are its functions. reporting meki nzewi, pavlicevic (2002: 1) argues that music in africa is healing and what is music therapy other than some colonial import? why is music therapy separate from music making? why is it calling itself thus in south africa, instead of imbibing african music healing tradition? the viewpoint above is encapsulating and it remains the core zone, which requires careful understanding. the therapeutic potency of music has been reported in malawi (friedson, 1996), in congo (kongo, 1997); and in nigeria (omibiyi-obidike, 1997; mereni, 2004; aluede and aiwuyo, 2016). as it is in africa, nigeria recognises more than a variable in disease causation. music therapy as a general nomenclature is not bad but if the name is to be adopted fully in nigeria, its scope must Jones:

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Backgrounds, histories and encounters   be enlarged to entail cultural and clinical approaches. sharing a similar opinion, nzewi remarks that: preventive health includes scheduled and mandatory environmental cleaning avoidance rites to ward off evil forces (human and of spirit mien), as well as constant musical arts theatre that coerces mass participation, annual group spirit purgation music-drama (new Year rites), compound hygiene etc. (2006: 2)

in your article, you mention, as an example of practice, work undertaken by twichell, describing him in the following manner: ‘one time eckankar living master, the hu sound pronounced (hiu) rules the entire universe. in his view, a moving engine, the overall sound from transactions in the market, sounds of waterfalls and oceans have that hu sound of life. thus hu sound heals, rejuvenates and enlivens who ever sings it’ (2006: 32). can you connect this to your previous comments about music and ‘enlarged’ cultural and clinical approaches? aluede: musical sound naturally has therapeutic potency. in most african societies, living to an old age is seen as god’s favour which everyone prays for. although life is a preparation for death, Bhaktipada, opines further that ‘death is like an arrow that is already in fight, and your life lasts only until it reaches you’ (1988: 49). so, death hovers around every mortal but by one’s careful habits, discipline, religious observances of age-old truths and caution in daily living, one can live a long and healthy life. music though not charm, talisman or amulet has been observed to share the attributes of Edae1 in calming someone, diverting ones thought from a gloomy to gay one and strengthening a weak mind to heal the body. music is often said to be a diversionary tool because it makes the mind to rise above the challenges that would have weighed the body down. on the link between the mind and the body, siegel remarks: Jones:

the state of the mind changes the state of the body by working through the central nervous system. peace of mind sends the body a “live” message, while depression, fear and unresolved conflict give it a “die” message. thus all healing is scientific, even if science cannot yet explain exactly how the unexpected “miracle” happens. (1986: 3) without a doubt, a depressed fellow can go into some forms of antisocial conduct such as drunkenness, poor health habits and even commit suicide. such acts could abbreviate an individual’s life span. conversely, a calm mind reduces one’s susceptibility to disease and illness. in the present day medical practice, exercise is constantly mentioned to be good for the heart. while it is not easy to religiously keep to a fixed timetable for ‘exercise for exercise’ sake, music in nigeria being an eclectic art form is replete with polyrhythm and highly intertwined with



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dance. music making in sub-saharan africa is a form of exercise in that musical activities go with dance, drumming, hand clapping or other forms of instrumentation. in all, it will not be superfluous to further mention that all these are physically challenging. music in nigeria is known to be commonly combined with dance whether under the entertainment, religious or ritual situations. dance strongly intersects with music and both go hand in hand while nourishing the human soul. it is, therefore, evident that the mind has so much influence on the well-being of humans. the holy Bible in proverbs chapter 17 verse 22 says that: ‘a cheerful heart is good medicine, but a crushed spirit dries up the bones’. one may ask: what makes a cheerful heart? the answer is music of good tidings, good instrumental accompaniment and culturally accepted sound. music, which is often regarded as the food of the soul makes a cheerful heart. what makes a crushed spirit? – anger, grief, pain, sickness and unresolved crises. what is the biblical significance of bones as used in this context? the bones as used in this context mean the mortal bodies. china, india, egypt, greece, rome, africa, the americas, all had civilisations that used chanting, toning, singing, loving speech, for selfhealing. all music was live, and vocal music was the most alive of all (timothy, 1999). chant choirs have existed in india, china, africa, and even the chant choirs of catholic church. in his bid to investigate a strange illness that had come over a Benedictine monastery in the south of france whereby seventy out of ninety monks became depressed, lethargic, fatigued and unable to perform their daily tasks, the french surgeon, alfred tomatis, noted that their new abbot had drastically reduced their chants like ‘Gloria in Excelsis Dei’ and when this chanting stopped, they became tired and depressed and as soon as they returned to the old order of chanting between eight and nine times a day for about twenty minutes each, dramatic changes occurred because the monks’ health was restored (cottrell, 2000). Jones: as you are aware, one of the tensions – often discussed in the literature – talks about the potentials and challenges of the relationship between what is often referred to as ‘traditional healing’ and the medical model in relation to how contemporary arts therapies understand change. what are your thoughts about how the kinds of traditions and practices in nigeria, such as those of twichell, relate to such debates? aluede: twichell unequivocally talked about the powers inherent in the hu sound. By extension – musical sound and its healing attributes. without much debate, it has been observed that many gains are accruable to the individuals and communities where music therapy is practised. mind and body intervention is one of the complementary/alternative medicine (cam), and included patient support groups, meditation, prayers, spiritual healing and creative outlet therapies involving the arts, music and dance (heather and chiho, 2012). however, nigeria can be said to be in the inclusive system of integration. music, which is an aspect of cam, has gained recognition in the western world as an adjunct

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Backgrounds, histories and encounters   to healing and well-being of the individual, and it is being integrated into the mainstream healthcare system, especially in europe and the united states. sadly, the same cannot be said about nigerian music healing. the relevant bodies in nigeria have partially recognised herbal medicine. one cannot deny the fact that holistic integration of proven evidence-based music healing and appropriate and effective utilisation of proven ethnic healing music will have immense benefts to the individual and health system in general (aluede and aiwuyo, 2016). in nigeria, healing songs play vital and initiating roles. to many orthodox medical personnel, this has not been proven through evidence-based research. in an effort to subject discoveries to rigorous scrutiny, all the concerned parties would need to evolve a common template for the assessment of progress in this direction. this should be the case because while orthodox medical practitioners may be most concerned about clinically based research evidence, experts from other backgrounds may be insisting on other variables than the clinic. this is because to many africans, there are multiple variables in disease causation.

in terms of an account of the arts, healing and therapy we can see here the ways in which ‘emergence’ is a complex notion and process. the interview reveals a phenomenon occurring in many countries, noted in chapter 7 and in the wider literature. this involves our attempts to understand the nature of the relationships between centuries-old traditions concerning the arts and healing and the emergence in the twentieth century of practices and identities named as ‘the arts therapies’. aluede’s interview illustrates elements of the dynamics of this process, common to many analyses. aspects include the relationship between different ways of understanding and being with health, ill-health and healing and the arts; how the nature and defnition of practice is complex and refects debates, discoveries and challenges as change occurs in a society’s ideas, policies and practices. the account also shows the ways in which different narratives are connected – how the arts, healing and therapy are connected to other histories within a country, such as the complexities of national identity, colonisation and power. aluede shows that our notion of history itself is subject to tensions and prejudice: for example, in the prioritising of powerful cultural traditions of textual evidence and accounts over expressions that do not rely on the written word. gwinner engages with this area, identifying how in some countries the acknowledgement of multiple perspectives on the nature of healing, healthcare and the arts are leading to new developments in defning and understanding the arts therapies and their histories: aboriginal and torres strait islander perspectives of the arts as inter-relational and inextricably tied to mental health and physical, cultural, and spiritual health are increasingly incorporated into discourse and understandings at the arts, therapy and health nexus in australia . . . such contextual



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definitions are shifting inward looking or siloed descriptions of arts, therapy and health and (instead) embrace a sense of collective identity, place and belonging. (Gwinner, 2016: 10) here gwinner notes the potentials that can arise from the acknowledgement that the ‘range of diverse philosophical and theoretical considerations underpin the role of art in healthcare in australia’ (2016: 10).

The first happening and Black Mountain College one of the strong threads within the histories of the arts therapies in many countries connects to the idea that in the twentieth century disciplines that were previously kept apart were brought into contact with each other. this occurred in a variety of different contexts, but there can be no doubt that the recorded emergence of terms such as ‘art therapy’ or ‘dramatherapy’ occurred for the frst time in this period. this emergence grew out of the ways in which cultural change occurred, creating contacts and opportunities for interdisciplinary questioning and experiment to blossom. if you like, it was the ‘step before’ the terms and specifc concepts emerged – i use the term ‘catalyst’ for this. the following is my interpretation of one such opportunity: that of Black mountain college as, out of the 1930s great depression and the effects of fascism in europe, a group of unlikely people are brought together. on monday 27 november 1933, speaking little english, Josef albers arrived at Black mountain college, north carolina, usa, on the southern railway. his work with the revolutionary Bauhaus arts movement had been abruptly halted, following raids by nazi stormtroopers and by the city council firing him from his post in what they described as ‘a germ cell of Bolshevism’ (wingler, 1969: 1880). within a few weeks he had been elected professor of art at the Black mountain college. he and others, pioneers in the avant-garde and refugees from fascist germany, came into contact at the college with artistic revolutionaries such as the musician cage, artist rauschenberg, perls, an innovator of gestalt therapy, and dancer cunningham. its advisory council included carl Jung, albert einstein, John dewey, walter gropius and franz kline – all key names in the revolution of ideas in areas such as psychology, education and the arts in the twentieth century. Black mountain college was founded by a group of people, many of whom had become unemployed in the great depression of the early 1930s. harris (2001) has described it as founded in the spirit of experimentation, idealism and international turmoil. the origins of the approaches of the college had their roots both in the revolution in art in america, and also in the artistic revolt that had begun in europe. however, as the varied composition of the advisory council hints, the connections occurring at Black mountain were more complex than this.

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i want to use the story of the Black mountain college to illustrate the ways in which the fervour and combustion of different realms of experimentation created the catalyst for the arts therapies. the thinkers and practitioners at the college were at the forefront of radicalism in the areas of arts, psychology, science and of ideas about the individual and society. my point is that Black mountain was not unique in this, but it is an example of places and groupings where the collisions and connections that created the arts therapies started to occur. previously held notions and practices were challenged in ways which show how the time was right for the ideas and ways of working to emerge which would make the arts therapies possible. albers, for example, was an advocate of abstract art. working with him were people such as drier, brought up in a new York household in a family devoted to the arts, social action, women’s emancipation and improved conditions for people with mental health problems: all influences which he brought into his participation in the forming of Black mountain college. a combination of new ideas about education was at the core of the venture. the emphasis was on creating a college where the arts could be explored as an experimental, improvisatory active process, rather than as a place for passive learning. work undertaken by students respected individual capacities and interests and the ‘creative spirit’ of the individual was fostered. the education focused on dramatics, music and the fine arts. there was a declared emphasis on the value of being sensitised to movement, form, sound and other media, and on their effect on the self and the environment. the arts were seen ‘as a force penetrating to the deepest levels of community life’ (harris, 2001: 16). one of those involved described the college as ‘total freedom to experiment, to perform, to get feedback’ (June rice interview, harris, 2001: 182). the place was engaged with the advanced edge of thinking and movements of the time: of Jung, sauer and artaud; of gestalt and jazz. though the college did not advocate one specific method or ideology, certain themes were echoed or shared. musician cage ‘considered art and life to be the same, though art is distinguished from life by being set aside as “a special occasion”’ (harris, 2001: 182). for artist rauschenberg, ‘painting relates to both art and life. neither can be made. (i try to act in that gap between the two)’ (rauschenberg, 1959: 2). here is a parallel concern with living and art, or art as living. the 1952 Bulletin of Black mountain college emphasises a search for the primary energies or propelling forces at the heart of both art and life. goodman, contributor in creative writing and drama at Black mountain, reflects yet another angle on the relationship between living and art. he brings together directly the fields of art and therapy. whilst at Black mountain goodman was working with perls and hefferline on the seminal text Gestalt Therapy (goodman et al., 1951). goodman, in his teaching, drew on gestalt and his knowledge of reichian therapy. in art classes, for example, goodman asked students to draw on their own feelings and experiences through reichian exercises in relaxation, to increase awareness and free the body from tension (harris, 2001: 212). it is not too great a step to see this approach as foreshadowing the art therapy



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practices of cameron fifty years later as described in chapter 3. her work also combined relaxation activities, image making and personal awareness but in the context of conflict resolution with people who were homeless in new York city. theatre tutor and practitioner olson was seeking, in artistic work, ‘an expression the equal of the original fact’. harris cites that art as a medium for change through an ‘alchemical process of transformation’ emerged as a groundbreaking concern within much practice at Black mountain (harris, 2001: 182). punning on avant-garde, with ‘advance-guard writing’, goodman, for example, wrote about the crucial need in society for the artist, and the necessity for art in community experience. he spoke of its important function in mediating key aspects of individual and social life – at birth and death, for example. his ideas concerned a search for a way of working which vitally connected the creative act and the community (goodman, 1951: 376).

Theatre Piece No. 1 this combustible mix at Black mountain saw schawinsky create what has been described as the frst examples of performance art, linked to Bauhaus ideas of non-narrative form, using music, lights and movement, emphasising ritual over verbal text. this is documented in his sketches for Spectodrama: Play, Life, Illusion (frst published 1936). at the same time leger gave demonstrations and classes on his ideas of Ballet méchanique (harris, 2001: 78). the work of graham and infuences of laban in movement were present in the work that was undertaken at the college. merce cunningham improvised with John cage (harris, 2001: 156), combining elements of hindu dance and i ching, in particular identifying ways of releasing conscious control and breaking habitual patterns of creating – a method of composition that attempted to challenge concepts of logic and meaning in art.

Theatre Piece No. 1 Black college is often cited as the site of the frst ‘happening’ staged by John cage in 1952. cage staged the improvised theatre piece no. 1 (harris, 2001: 40). he conceived the piece after lunch and it was performed that evening. each performer was given a time bracket that had been arrived at by chance procedures. in this period they had to enact a particular activity. cage had a rough idea of what they should do, but nothing specifc. the people didn’t play fctional characters but were themselves. the work took place with no rehearsal, script or costume.

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emphasis was on chance, on the integration of audience and performer, on the freedom to determine one’s own work. action took place all over an auditorium: in the aisles and in the areas between the chairs. some of rauschenberg’s all-white paintings hung in a cross from the rafters, along with a painting by kline. there were many foci within the performance: cage reading aloud on a ladder, whilst others did so from other ladders, cunningham dancing in and around the chairs was joined by his dog. rauschenberg stood by his paintings, or played edith piaf records at double speed, tudor played a piano and a radio. films and still pictures were projected upside down and on angled surfaces. coffee was served in ashtrays used as cups.

the arts were seen as essential to life and their role that of a generative force in a culture rather than ‘distraction’ or entertainment. albers said that art should not be a ‘beauty shop’, or an imitation of nature, an embellishment or entertainment, but rather ‘a spiritual documentation of life . . . real art is essential life and essential life is art’ (albers, 1934: 111.1). the point i’m making is that this kind of exploration and pushing of boundaries in the arts, and in therapy, was happening in a variety of places. ideas were stretching out, making new contacts: the particular ways that experimentation in different disciplines was taking shape created opportunities for discoveries to occur. the social and political upheavals and the increased opportunities for communication, such as the displacement of individuals caused by the rise of fascism or the 1930s depression, are witnessed in the above-created connections. the concerns at the heart of these revolutions and innovations in separate disciplines meant that the ground was ripe for the arts therapies to emerge. what are these concerns and connections? in the above description we see the following practices and preoccupations: • •

•

•

artists who are paying attention to the importance of process, on the effects of the making of art as compared to the primacy of the finished product; concerns about the effects of this process on people, the ways in which the arts can function to affect people in their lives, in the way they encounter key stages in their individual and collective lives – such as birth or death; an educative philosophy and the creation of methods that emphasise the development of the individual and the importance of their potential – arts as education developing the student’s potentials rather than being taught existing material within a strict curriculum; experiments with the new opportunities which artistic expression is offered from improvisation and spontaneity, with interest in the immediate and unplanned rather than the rehearsed and planned;

 •

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individuals writing about, and discovering, ways of working and understanding identity and therapy whilst being involved in the arts – goodman, perls and Jung, for example.

painters, theatre practitioners, dancers, musicians, psychologists, therapists came together and were working within an environment that was conducive to interdisciplinarity and to the breaking down of boundaries. hence experimentation in one area was open to the repercussions brought from discoveries made within other fields. discoveries about spontaneity and the arts were reflected in the findings and practice of gestalt therapy, for example. actors and dramatists were adapting therapy-influenced techniques in their preparation, artists were making use of the ideas about consciousness to work with improvisation and discovery. arts therapists such as Byrne (1995) have pointed to the ways in which such revolutions in the arts influenced the development of the arts therapies. a part of this is well summed up by read Johnson: improvisation is a relatively late development in the arts and seems to have emerged in all art forms in the twentieth century, in jazz, in expressionist painting, modern dance and improvisational theatre. the stretching and altering of rigid artistic forms seems a characteristic of this century’s art, and clearly created the conditions under which the creative arts therapies could develop. (Johnson, 1999: 25) movements such as surrealism, modernism, abstract expressionism, arte povera with their interests in the unconscious, automatism, dreams, inner feelings and impulses linking to artists’ ‘gestures on canvas’ and the arts ‘profoundly influence both our theory and our practice’ (Byrne, 1995: 235).

Conclusion this chapter has illustrated the complex relationships between emergence, defnition and the presence of the arts, healing and the arts as therapy. the experiences of gómez carlier and salom in colombia, and aluede’s analysis interrogate and challenge notions of the arts therapies in terms of identity and history. the people at Black mountain college didn’t come up with the specifc disciplines of the arts therapies, nor with their techniques, or direct, therapeutic aims for the arts. however, the kinds of questions being asked, and the kinds of work being undertaken, threw up relevant possibilities in their experimentation. the arts therapies were born and are still developing within this same spirit of challenge and unrest with a status quo, of cultural, political and artistic experimentation and enquiry. the illustration of the ‘first happening’ event of 1952 is in the spirit of the arts therapies. in relating some of the story of albers and Black mountain,

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and by highlighting the way ideas and processes were being exchanged between disciplines, certain concerns can be seen. these concerns and connections show the ways the arts therapies were in the air. it was not by chance that the arts therapies formed, but by the coming together of different developments in different fields. it happened in many places at around the same time. the time for such connections and the creation of the term and modern emergence of the arts therapies was right. the next chapter explores a strand of this history further to illustrate the nature of how the arts therapies have formed and become accessible to people.

Note 1 edae is an esan term for an amulet or potion, which is either worn on the neck, waist, hand or hung on a tree or on a roof top to elongate the life span of its user provided it is secured and applied as directed. it is also believed that on being loosened from the user’s neck, removed from the roof top or tree top and brought in contact with the ground the user dies when a ripe old age has been attained (aluede, 2010: 77).

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Introduction: many places In many places practices such as artists working in hospitals, teachers using the arts with children, cultural practitioners engaging with groups and individuals in community contexts, or occupational therapists and psychiatrists using arts activities within their work were developing in ways that led to the named, identifed discipline and profession of the arts therapies. This had occurred for many years in many different countries, from the Bellevue Hospital in Jamaica (Hickling, 1989) to India (Jones, 1996). Though the wide extent of such practice was new in many countries, some of the basic ideas, such as the presence of the arts in asylums, for example, was not. As has been shown earlier, there was a tradition of art studios and performance spaces for music and theatre. Nizamie et al. (2008) describe an ongoing tradition at the Central Institute of Psychiatry, Ranchi, in the Indian state of Jharkhand, which has held weekly dance and music ‘socials’ since its establishment in 1918, shortly followed in the 1920s by the hospital having a music band of its own. Charenton, an asylum outside Paris, held theatre productions involving patients. Coulmier, director of the asylum, was involved in creating them between 1789 and 1811, along with de Sade, who wrote some of the productions whilst an inmate there (Jones, 1996: 47). Arts activities became much more common in such settings by the mid-twentieth century. In South America, Coqueiro et al., for example, note the work of two psychiatrists during this time: Osório César in the 1920s and 1930s who worked with art at Hospital do Juqueri, in São Paulo, Brazil, and ‘was mainly influenced by psychoanalysis’, whilst Nise da Silveira developed her work in the 1940s at Centro Psiquiátrico Dom Pedro II (Psychiatric Center), in Rio de Janeiro, and worked with art, ‘largely influenced by Jungian psychiatry; both aimed to understand patients’ artistic expressions’ (Coqueiro et al., 2010: 860). Fryrear and Fleshman (1981) have said that much of this activity was ‘caretaking’ rather than therapy, and say that this kind of attitude and situation prevailed until well into the 1940s in many countries. The idea here is that the groundwork for the emergence of the specific, named discipline of the arts therapies lay in such arenas of activity. One example is the arts and crafts movement that was taking place in many 89

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contexts and often linked to hospital occupational therapy, though this was largely seen as recreational (Fryrear and Fleshman, 1981: 14). Van de Wall, in 1936, for example, illustrates this attitude well, as music is placed alongside fresh air and flowers: The hospitalised patients should enjoy music as a cultural and social interest and occupation that is entirely divorced in their minds from concepts of illness. The sheer contact with efficient and sensible musicians and with an art that, like fresh air, sunshine and flowers, introduces in the ward elements of joyful cultural and social living, has value in improving the quality of his [sic] life and pervades it with ideas, feelings and events which are part of normal social life at its best. (Van de Wall and Liepmann, 1936: 8) Alongside the development of therapeutic work with clients in hospitals, arts work became more common in schools, educational units for pupils with ‘special educational needs’ and other settings such as day centres for adults with learning disabilities (Jones, 1996). As mentioned earlier, such discoveries were occurring in many places. A parallel process occurred in Japan, for example. Sharmacharja (2016) and Watanebe (2015) contextualise the development of the arts as therapy in the work of Omi Gakuen: During the postwar era, many social welfare establishments were created in Shiga Prefecture, including the child welfare facility Omi Gakuen, which was founded by Kazuo Itoga, Ichiji Tamura and Taro Ikeda in 1946. One of the then-unique activities of Omi Gaukuen was the use of craft therapy, which without the usual rules or restrictions of an art education gave participants total freedom of expression. (Watanebe, 2015: 17) Okazaki-Sakaue (2003) notes that music therapy began to be practised in the 1950s and 1960s with people from different professions coming into contact, such as psychiatrist Dr Matsui, psychologist Dr Yamamatsu, and Dr Murai, who was both a musician and psychiatrist. He notes the importance of Alvin, founder in 1958 of the Society for Music Therapy and Remedial Music in the UK, who visited Tokyo in the 1960s, and whose work was translated by Sakurabayashi. Interestingly, making connections between the excerpts in the next section from a conference held at King’s College London in 1960 and Japan in the same decade, the London conference speeches by Judges and Gruhn featured below were followed by one made by Alvin. The translation of Nordoff Robbins into Japanese, in 1972, is also seen as a significant factor in the development of music therapy there (Okazaki-Sakaue, 2003). This follows the pattern we’ve been identifying and that has been common in many countries. In the mid-twentieth century ‘individuals began

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practising in institutions such as welfare centres, nursing homes, rehabilitation facilities and hospitals. They also formed several music therapy study groups, some of which later became local associations’ (Okazaki-Sakaue, 2003: 1). Two associations were formed – the Clinical Music Therapy Association and the Bio-Music Association – which joined together in 1995 to become the Japanese Federation for Music Therapy (JFMT). This was not a static situation, where arts practices from outside health and education were ‘shipped in’. The therapeutic and special educational settings began to affect the way the arts were seen and practised – the responses, needs and situations of the clients in the institutions or hospitals began to illuminate particular facets and capacities of the arts. This was noticed by the practitioners, and began to affect the direction and application of the arts. By this I mean that practitioners began to perceive that the arts seemed to have particular kinds of impact on the ways people behaved, related to themselves and others, their emotional conditions and the ways they could express themselves. The practitioners facilitating these arts activities began to see new potentials in the arts that would connect to therapeutic potentials for the people they worked with. Crucially, the nature and level of the work began to change, as I will now show.

Conference of the Society for Music Therapy and Remedial Music, 1960 As noted above in the examples from Brazil and Japan, individuals began to be aware of each other’s practice and discoveries, small groups developed and these began to discover and to be connected with other such groupings. Eventually this led to the formation of associations of arts therapists (Jones, 2007). In the 1950s and 1960s, especially, we see an increasing number of conferences, summer schools and opportunities for people to gather. From these connections training and professional associations grew. Here is an illustration from an opening speech and paper by Judges and Gruhn from such an event in London in 1960.

The Society for Music Therapy and Remedial Music OneDay Conference on Music Therapy, London, 30 April 1960 OPENING ADDRESS Professor A.V. Judges, Head of the Department of Education, King’s College We are here amongst professional educationalists, and perhaps with some sense of mission, inasmuch as educationalists, even those who have to do with learning problems among the abnormal and unsophisticated and retarded, are only too prone to think that people grow and mature almost entirely under intellectual stimulus, and that progress

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will submit to test only by verbal analysis. Well, of course this is an outmoded view. It goes back to the time when inspectors of education measured growth by literacy and literacy by intellectual learning achieved, whether in the D stream or A stream, by young people sitting bolt upright in trance-like rigidity on knife-board benches and with their hands clasped before them. We are now discovering once more, and very slowly indeed, that ease and strength in making progress, and also in fnding one’s personal role depend quite as much on emotional involvement, and on muscular exercise and co-ordination and in all kinds of felt experience – all of these taking place on any but an intellectual plane. At this Conference, we study especially the parts played by music and rhythm. I have mentioned the broader field of experience, because in a sense we are only specialists representing one stream in a current of new ideas which also embrace new practices in the use of dramatic action and role-playing, and free movement too and painting and modelling, all of which have accepted remedial uses as well as more orthodox parts to play . . . thus the therapeutic uses of painting and drawing are growing more important. One wonders how far these parallel experiments with the therapy of self-expression have a bearing on one’s own interests to-day. Sometimes the life of the expressionist artist in the ward is short. Diagnosis is easier, treatment is nowadays more confident. There is more affection (at least in some asylums), more opportunities for restoring courage and uplifting broken spirits. And there are new drugs for some cases (whether permanently effective I don’t know) which seem to produce miracle cures. For art teachers, paradoxically enough, perhaps the most disheartening incident in the curative regime is the sequel to one of these quick recoveries after drugs. Gone suddenly are the brilliancy, the love of contrasting colour, the abandon, the acrobatic draughtsmanship. And the same artist now smugly presents prim and conventional little pencil drawings of houses and gardens – no longer the serpents and rearing dragons and wild horses. This apparent collapse of artistic activity is a sign for discharge, and for the relatives to come and take the cured patient back to normality! (Judges, 1960: 1–2) MUSIC THERAPY IN ENGLAND Miss Nora Gruhn, Music Therapist, Warlingham Park, Cane Hill and Netherne hospitals It was in 1947 that the Council for Music in Hospitals was formed to provide monthly concerts of high quality music in mental hospitals. This work has continued most successfully until today; many professional musicians give concerts in hospitals all over the country.

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It was from America that the first financial help came to employ musicians to work part time in mental hospitals. From that initial encouragement emerged the Association for Music Therapy in Hospitals. Another more recently formed society is the Society for Music Therapy and Remedial Music who have sponsored this conference today. The exciting thing about the position in this country is the challenge offered by so much pioneering work ahead. There is still some disagreement about methods especially on the type of training a musician or music therapist should receive. Some doctors consider medical knowledge unnecessary, and would like to employ a musician without any other training. Others would like their nurses who have an interest in music to take a special course of training for this work. Personally I favour a three year course at one of the Music Colleges with a further six months’ training at a hospital giving lectures and practical work which would lead to a professional status of music therapist. Without some medical knowledge the musician must work blind to any therapeutic goal, and this, to my mind seems undesirable. ... The word music therapist is used so loosely that naturally it is very unpopular with doctors. Therapy comes from a Greek word meaning treatment to cure or alleviate disease. As the only persons authorised to do this are the doctors it follows that a therapy should be limited, frst of all, to a prescription given by a doctor. Where a musician is not working under the direction of a doctor the work would seem to me to be only recreational. Whether in this country we shall ever have music therapists conforming to these ideals is very uncertain at present. The future of music therapy lies in scientific research aimed at results which will convert the sceptics, and act as a basis on which to build new techniques. (Gruhn, 1960: 4–5)

The timing of these speeches is interesting – made in the middle of the period described above, when those involved in the arts therapies in some countries were forming into associations, individuals were developing techniques, ways of working, concepts and trainings. Judges shows himself aware of the time he is speaking: of being part of what he calls ‘one stream in a current of new ideas’ relating to ‘new practices in the use of dramatic action and role-playing, and free movement too and painting and modelling’. As noted in Chapter 8, the development of the arts therapies as professions can be usefully divided into three phases within health services and provision

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in many countries. The first phase is the presence of artistic activities in health and education settings as recreation or occupation. The second is that the arts become seen and acknowledged as having some beneficial effects, but that this is offered as an adjunct, addition or subordinate activity to the major means of ‘treatment’ or therapeutic activity. The third is the gradual establishment of the arts therapies as independent therapeutic modalities capable of engendering change in their own right (Jones, 1996; Bunt, 1997; Bunney, 2013). In these speeches we can see illustrated some of these stages reflected within the words of the speakers. Before we look at this, to help us see these processes at work, I want to parallel it with another account of the development of the arts therapies in the UK in the early 1960s. One of the key pioneers of the arts therapies, Sue Jennings, describes events that were happening at the same time as the Music Therapy Conference but in another part of London and in nearby St Albans: The Remedial Drama Group I started with Gordon Wiseman in the early 1960s. I was doing remedial drama at a special school in St Albans before the Remedial Drama Centre opened and at St George’s Hospital, a psychiatric centre there, and also at the Marlborough Centre, as an instructor explicitly to do drama. There was an interest in ‘doing drama with special needs’. I was also employed by the London School of Occupational Therapy to teach OT students. I also worked at a special nursery in St Albans. Drama and music were seen as ways of enabling children to do things that otherwise they couldn’t have done. Quite a lot of work we were doing was helping maturation to happen . . . Maturation steps were gained and retrieved through drama; steps that hadn’t been there, or had been lost through institutionalisation, for example . . . because play reading and drama activities were seen as ‘a good thing’ in the 1930s and 1940s, it was therefore easier for the likes of us to take it a stage further in the 1950s and 1960s . . . Everything was ripe. Art therapy started as remedial art. St Albans College of Art had a first course in remedial art before it became art therapy. We called our thing remedial drama and it was almost as if one had to make an enormous step to call something therapy. But it was about 1970 that the step from remedial drama to dramatherapy was made. (Jennings in Jones, 1996: 90–1) In these accounts we can see different areas being drawn into contact – education, psychiatry, therapy, the arts. The Music Therapy Conference includes educators, artists and therapists as its anticipated audience. Jennings talks of a life busy innovating in education and special education for children with learning difficulties, whilst also working in mental health

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wards in hospitals alongside practice with occupational therapists. You can feel in the accounts that relations between fields such as the arts, therapy and education were growing out of their different contexts and coming into contact with each other – as artists, educationalists, therapists met and as pupils in schools and patients in hospitals made connections between different parts of their experiences. You can also feel the early ‘sense of mission’ as the first speaker says, as these areas were being brought into a creative connection. It’s not as if these people knew exactly what they would find. They were often following a mixture of intuition, exploratory zeal and pursuing what they noticed was happening as they used the arts or were involved in therapeutic activities in such settings. The use of language is interesting. The time-bound descriptions of ‘the abnormal and unsophisticated and retarded’ in the first speech are an indicator of the shift made from the era at the start of the arts therapies, and are clearly different from contemporary understandings of difference and disability. However, the language is also useful to consider the process I described earlier, as the arts therapies emerge from rehabilitation or as being only an adjunct to therapy. Both Jennings and Judges refer to the shift from ‘remedial’ work to ‘therapy’. It’s worth looking at these terms as they occur in many accounts of the historical development of the arts therapies (Jones, 1996; Bunt, 1997; Gilroy and Lee, 1995). Judges talks of the idea of ‘remedial uses’ of the arts, initially, and this is followed by a shift in the next sentence saying that ‘the therapeutic uses of painting and drawing are growing more important’. Similarly, Jennings talks of the hesitancy to make an ‘enormous step’ to call what was happening therapy rather than a ‘remedial’ art. It’s almost as if we can see the step being tried out during the opening address as Judges, interestingly and significantly, shifts in one sentence from ‘remedial’ to try out this interesting phrase: ‘growing more therapeutic’. The arts therapies were making this step with Judges at that time, becoming clearer about what it was they could offer, moving from an ‘adjunct’ to a mode of therapy in their own right. Gruhn goes on to speculate what would happen if music therapy could develop (beneath the critical gaze of doctors, ‘the sceptics’). Gilroy and Lee, in their review of the histories of art therapy and music therapy, draw attention to attitudes towards the nature of these changes in the period of the 1940s and 1950s. They, too, comment on the tradition of arts as occupational activity, but also on the use of art or music as ‘inherently healing’ processes (Gilroy and Lee, 1995: 2). They refer to traditions such as those developed by Hill, where patients made images in a studio-based environment (Hill, 1945, 1951), or the use of pre-composed or improvised music within work with children by Nordoff and Robbins (1971), focusing on work with a piano and percussion. They also include Alvin’s work using a range of instruments and looking at the structure and elements of music within a therapeutic relationship (Alvin, 1965). These examples involve the ‘step’ that the 1960 Music Therapy Conference speech by Judges alludes to, and is illustrated in its move from the use of the terms ‘remedial activity’ to ‘therapy’. There has been a crucial

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change in the arts therapies from the arts as being seen to be ‘useful’ in a therapeutic or care context, but needing the context of another more accepted form of treatment or therapy – such as drug treatment or psychiatry – to be effective or safe. The art form looked at in this way can still be used in only recreation or diagnosis, or in evoking material that will be worked with by one of the accepted modes of ‘treatment’. In 1950, for example, in his book Drama Therapy, Solomon can still write that drama can be used with a therapeutic intent only if connected to another form of treatment: ‘This therapeutic intent, however, cannot be accomplished by the use of drama alone, but drama used in conjunction with the technique of psychiatry and psychoanalysis in a group psychotherapy setting’ (Solomon, 1950: 247). In discussing the history of dance therapy, Bunney uses parallel concepts: We have come a long way from some reports in the early literature referring to dance therapy as ‘adjunctive’ therapy. With the establishment of graduate training programs requiring research theses, as well as credentialing standards for training and practice, we, as practitioners of mainstream therapy, have evolved into a profession. (Bunney, 2013: 6) This attitude did not die out overnight. Many would still recognise it, especially in countries where the arts therapies have not been recognised formally by the national or major providers of healthcare. As late as 1989, art therapist Edwards, working in a large hospital for clients with mental health problems in England, can write about the expectations in his setting that art therapy is either concerned with diagnosis only, or with recreation: The issue of professional autonomy and recognition so often discussed by art therapists was one it was necessary to grapple with shortly after taking up my post. At that time the art therapy service was managed by the head occupational therapist and there appeared to be little immediate prospect of any change in this arrangement. Still more disheartening was the realisation that art therapy was widely regarded as an essentially diversional activity, with the art therapy hut being seen as a place to send patients en masse in order to keep them occupied. (Edwards, 1989: 169–70)

Transitions Edwards, however, notes that he achieved a shift, both out of the occupational therapy department and in perceptions of the nature and function of art therapy. This he sees as a position where art therapy was regarded as a

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‘valid way of working with people in need’, and as a ‘therapeutic intervention’ in its own right (Edwards, 1989: 168, 172). Judges’s speech also shows another link to the era of fascination with ‘psychotic’ art that is seen as qualitatively different and exotic: ‘For art teachers, paradoxically enough, perhaps the most disheartening incident in the curative regime is the sequel to one of these quick recoveries after drugs. Gone suddenly are the brilliancy, the love of contrasting colour, the abandon, the acrobatic draughtsmanship’ (Judges, 1960: 1–2). Here is the idea of a ‘special’ art, and that the quality of expressions can be clearly identified as illustrative of psychiatric illness. The notion of health is paralleled with pictures of ‘smugly presented prim and conventional little pencil drawings of houses and gardens’. There’s no doubt there that the speaker prefers what is referred to as the serpents, rearing dragons and wild horses. He is almost nostalgic that an ‘apparent collapse of artistic activity is a sign for discharge, and for the relatives to come and take the cured patient back to normality’. A part of this may be linked to the expressions that can accompany certain conditions, but we can also see his response as linking to the attitudes and movements of which the Prinzhorn collection is one of the most recognised examples: the interest in the artistic expression of ‘the insane’ as ‘outsider art’ – exotic, separated off and identifiable. Many, as we will see, would now challenge such ideas and comments. In this part of the speech, again, we can see a transition. Judges is clearly acknowledging the importance of artistic expression of the clients, and the validity of the experience of their mental illness and artistic products. However, this idea is still linked to a romanticised picture of art by people with mental health problems – of the ‘insane’ as outsider against the ‘smug’ world of ‘the normal’. There has yet to be the shift which sees any person as capable of artistic expression, and that the art in art therapy is, in itself, neither more nor less special than any other utterance, not set apart for ‘special people’. Authors such as Edwards (1989), Beveridge (2010) and O’Flynn et al. (2018) have looked at the history of such ideas and attitudes towards the arts and mental illness, for example. Beveridge draws on Foucault to challenge the ‘sunny view’ of galleries and theatres in asylums as a development of ‘a new era of humane treatment’ and settings such as these as ‘a model for other asylums throughout Europe’ (2010: 14). He positions such provision as connected to disciplines such as psychiatry and ‘more sophisticated forms of control’ (2010: 14), drawing on arguments summarised by Swartz as characterising ‘custodial care in mental institutions as political or inhumane, an attempt to discipline unruly bodies or rebellious souls’ (2008: 299). Instead of physical manacles ‘patients were induced to construct their own “chains”’ but these ‘served to constrict self-expression or any deviance from bourgeois ideas of decorum’ and hence the ‘voice of unreason’ was ‘silenced’ (Beveridge, 2010: 14). O’Flynn et al. reposition work framed as ‘outsider’ as complex: ‘simultaneously, artifacts of mental health and art therapy history, documents of therapeutic experiences, and works of art’ (2018: 396), raising issues concerning ownership, naming and terminology in relation to art created in such conditions. Their paper, for example,

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argues that ‘the maker, and not the institution, should own any artwork produced in a health-care setting’ and note recent moves to name artists: ‘framing the asylum inmate creators as artists with names rejects the denial of their identity and humanity, and the repetition of the injustice of their detention and exclusion. There should be no shame associated with living with psychosis. The naming of artists is not in a context of diagnosis’ (2018: 387). They cite Barham in a 2017 debate arguing that ‘not to name the creators is to deny them their human-ness and individuality all over again’. Barham argued that naming helps to establish a connection both with the art works and the creator, and is considered by many to be an important step towards redressing the ‘historical denial of identity, agency, and recognition perpetrated by the asylum system’ (2018: 398). Edwards cites examples from the display of the art of people in asylums, such as those shown in Hogarth’s depictions of Bedlam. He links such attitudes to being ‘diverted by the shocking spectacle of lunacy – an acceptable form of recreation at the time’ (1989: 78). One scene, for example, shows an open cell with an inmate drawing a moon, a ship and a geometrical shape on the asylum wall. It’s a tradition rooted more in nineteenth- and early twentieth-century attitudes in many countries as described by Edwards when non-professional work by ‘the mentally ill’ tended to be of interest for its curiosity value – ‘hospitals assembled little museums for fee-paying visitors’ (Edwards, 1989: 80). This is in sharp contrast with viewing art as a part of healing, and artistic expression as a way to achieve health. Schaverien draws attention to more recent UK art therapy attitudes where the notion that particular forms of artistic expression can automatically be linked with psychotic states is dismissed as too simplistic: that ‘imagery can be thought of as pathological. This can never be the case. The crudest versions of such assessments make assumptions regarding the type of imagery: for example, a client may be assumed to be psychotic because there are many disjointed elements in the picture, or a hat on the head may be considered evidence of a castration anxiety. Clearly such assumptions lack subtlety and an understanding of the complexity of the ways in which pictures come to be made’ (Schaverien, 1992: 3). Schaverien illustrates here some of the shifts in attitude and practice that the music therapy speech illustrates in transition. The way ‘the step’ has been made for art therapists such as herself is clearly illustrated. The image is not simply diagnostic for others to work with, nor is the art process only a recreational or occupational one. Here, demonstrated by her comments, is an illustration of the ways in which image production, and its relationship to therapy, is now more fully understood, more fully realised for the client as a way of engaging with change. It reflects a related but substantially different way of looking at arts processes and their relationship to change. The movement from ‘remedial’ to ‘therapy’, in transit in 1960, has been made. Schaverien describes a key aspect of the changes: This is because the art therapist takes account of the picture in relation to the artist. Thus they assess the whole

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person in relation to the pictures, and in relation to the art therapist. The juxtaposition of certain colours, shapes or images does not indicate disturbance in any finite way. A picture which is peppered with detached eyes or ears does not tell us that the patient is paranoid but it might indicate this as a possibility to be borne in mind in relation to other aspects of the person. There are no rules governing interpretation of pictures. (Schaverien, 1992: 3) Here is the final shift illustrated. The attention is on art therapy as the primary means of therapy, not as an assistant to other methods. The image is not seen as an interesting or exoticised curiosity. Nor is it looked at by her as a diagnostic indication of a condition to be handed over to other professionals to be cured by treatment through psychiatry or drugs, after which the client’s artistic capacity will vanish or lose its potency or relevance. The image, client and art therapist are seen within a process that Schaverien clearly elucidates. The image is part of a therapeutic relationship. Its function and complexity are acknowledged and worked with, the process is one that can result in therapeutic change for the client. Here are illustrated some of the key themes in current understandings of the arts therapies. It is echoed, for example, by the definition of art therapy established by the British Association of Art Therapists in 1989: The focus of art therapy is the image, and the process involves a transaction between the creator (the patient), the artefact and the therapist. As in all therapy, bringing unconscious feelings to a conscious level and thereafter exploring them holds true for art therapy, but here the richness of artistic symbol and metaphor illustrate the process . . . the expression and condensation of unconscious feelings that art making engenders are at the heart of art therapy. (Standing Committee of Arts Therapies Professions, 1989: 5) As we saw in Part II, this is in parallel with many contemporary definitions of change and outcome: the American Art Therapy Association stresses the therapeutic use of art making, within a professional relationship, involving creating art and reflecting on the art products and processes. It says that this process will result in outcomes for clients such as increased awareness of self and others; being able to cope with symptoms, stress and traumatic experiences; enhancing cognitive abilities; and enjoying the life-affirming pleasures of making art. In both of these UK and US definitions the three-way relationship between therapist, client and artistic expression, products and processes is identified as central to efficacy. By 1989 the UK Association of Professional Music

100 Backgrounds, histories and encounters   Therapists looks at the nature of change in a similar way. They say that music therapy: provides a framework for the building of a mutual relationship between client and therapist through which the music therapist will communicate with the client finding a musical idiom . . . [that] enables change to occur, both in the condition of the client and in the form the therapy takes. By using skilled and creative musicianship . . . the therapist seeks to establish an interaction – a shared musical experience – leading to the pursuit of therapeutic goals. (Standing Committee of Arts Therapies Professions, 1989: 6) I think these accounts can be summarised in the following way: • • •

The arts therapies can be a primary therapeutic modality and not only occupational or recreational Both definitions acknowledge clearly that specific changes in the client’s condition are expected outcomes of the intervention Whilst they can have relationships with other therapeutic modalities, the arts therapies are distinct therapies in their own right, with their own working theory and practices.

The nature of change is able to be described, and is centred around two areas in these definitions: • •

The artistic process, through areas such as image or sound, as a means of communication, containment and process within therapy The triangular relationship between client, art form and therapist as central to change.

What is important about this is that it illustrates that the arts therapies had reached a position where they can be offered to clients as therapies in their own right, and can articulate what processes and potential outcomes they work with. Key aspects of this will be defined later in Chapter 14, on the core processes of the arts therapies.

Professions In conjunction with the developments described above, processes establishing the arts therapies as ‘professions’ occur, connected to the development of associations. Ridder et al. describe a key aspect of their role as being connected to discourses of ‘protection’ and regulation: The professional associations play an important role in establishing particular overall standards, first of all with

‘Everything is ripe’ 101 the purpose of protecting clients from harm by formulating codes of ethics, and secondly with the purpose of protecting the profession and the title ‘music therapist’. (Ridder et al., 2015: 18) The process of such professionalisation varies between different countries and continents and between modalities as introduced in Chapter 8. Nöcker-Ribaupierre describes this from the mid-twentieth century in Europe in terms of the dynamic between three interconnected elements: ‘the first training courses were implemented, the first music therapists began to work, and the first professional organisations were established’ (2015: 23). She presents the development of training and professionalisation in Europe as a rhythm of individuals gathering and forming groups parallel to those described above: The development of music therapy in Europe and of the European Music Therapy Confederation (EMTC) is first of all a story of different music therapists, pioneers and musically educated therapists with different visions who aspired first to develop the profession, then to form a network in order to provide an official basis on a political level, with the aim to develop and to ensure the quality of the profession. All the EMTC delegates support the vision of strengthening the professional development in their own countries. (Nöcker-Ribaupierre, 2015: 25) In terms of training, a review in 2014 established the existence of 117 music therapy courses in 27 European countries, with 18 at BA level and 45 MA courses with 66 other courses, such as further training or graduate training courses (Schmid, 2014). Ridder et al. connect the establishing of the profession of music therapy to an understanding, recognition and demonstration of the value of the therapy to clients, with a key aspect of this being the presence of the arts therapy within formal provision within national health services. This is a complex and contested arena, discussed in Chapter 16, however, they position this as concerning the ‘formal recommendation of music therapy in national health guidelines’, with illustrations of national clinical health guidelines in Norway, Sweden and the UK where, for example, ‘the use of music therapy is recommended in the treatment of patients with psychotic disorders’ (2015: 18). The dynamic outlined by Nöcker-Ribaupierre between professionalisation, training and regulation of standards of practice is illustrated by Ridder et al.’s commentary connected to such national level guidelines and to access for clients: In the UK guidelines for schizophrenia and psychosis, it is recommended that ‘Arts therapies should be provided’ (National Institute for Health and Care Excellence (NICE) 2014: 221). Furthermore, it is stated that this should be

102 Backgrounds, histories and encounters   done ‘by a Health and Care Professions Council registered arts therapist with previous experience of working with people with psychosis or schizophrenia’ (NICE, 2014: 217). In the UK art, drama and music therapists are registered and regulated which requires specialist training at Master’s level. (Ridder et al., 2015: 18) Solomon’s comments on parallel tensions in relation to the arts therapies and South Africa, situating such relationships in terms of power and as more problematic in terms of a ‘gap’ between ‘Western and African practices in the professionalization and education of art therapists in the post-apartheid South African health system’ (2005: 3–4). She comments on an illustrative example of Maggie Makhoana, a black South African woman who had no access to art at school ‘because none was taught at Black schools with the 1956 Bantu Education Act of the Apartheid government forbidding it’ (2005: 8). Makhoana’s route to practice was through the ‘community art centres in which art could be made and exhibited’, the South African Art Foundation and teaching art to children in the townships in the 1980s. In interview Makhoana positions her work as art therapy: It is I who decides who comes to the art therapy . . . Yes, I do art with one group and art therapy with others. There were sixty-two this year and they dropped to fifty-eight. I am doing work with the remaining forty-nine. I do art therapy with fifteen of those. Some of these children are teenagers. I get children of all ages. These children are beginning to talk of issues which are important to them, and doing well at school. (Solomon, 2005: 9) Solomon identifies the complexity of someone in Makhoana’s position in relation to a structural organisation such as the Health Professions Council of South Africa (HPCSA). Their role is formally described through a framework of concepts and practices of legislation, gatekeeping and safeguarding connected to training, registration, employment and safety: The Professional Board for Occupational Therapy, Medical Orthotics and Prosthetics and Arts Therapy of the Health Professions Council of South Africa (HPCSA) has a legislative mandate in terms of the Health Professions Act 1974 (Act no 56 of 1974) to ensure the registration of adequately educated and trained as well as appropriately qualified Occupational Therapy, Medical Orthotics and Prosthetics and Arts Therapy practitioners for the rendering of quality and safe healthcare services to the public of South Africa . . . The Board has not accredited any training

‘Everything is ripe’ 103 provider in South Africa to offer training in Arts Therapy in the category of Art, or related professions . . . Parents and prospective students are urged not be misled to register at any non-accredited institution offering training in Arts Therapy in South Africa. Furthermore, employers are advised to ensure that they employ properly qualified and registered practitioners in the health care industry in order to ensure the safety of patients. (https://www.hpcsa-blogs.co.za/caution-ofunaccredited-training-providers-in-arts-therapy/) Solomon comments as follows, using a different framework from those in the HPCSA quotation, drawing on concepts of rights, social justice and exclusion, structural racism, and varied systems of knowledge and healing: Maggie and others like her were denied education and civil rights during the apartheid era. Now Western rationalism, as locally expressed in the exclusive practices of the HPCSA, continues to erase the contribution she made from the public record. Instead of treating her dedication with the respect it deserved, the HPCSA said she may not earn a living as an art therapist because she had not achieved the educational qualifications which apartheid and postapartheid poverty denied her. Maggie’s many years of pioneering experience in the townships nevertheless constitute a body of achievement South Africans should be learning from. The concept of acquired right is vitally important in South Africa if we are to benefit from the work of those pioneers who have struggled and paid their dues to society in a multitude of visible and invisible ways despite a lack of formal qualifications. Maggie had not acquired the paper qualifications the HPCSA required, and she and all the others working in the townships that are using art and artefact to heal the scars of racism and poverty continue to be known simply as cultural workers. For art therapists in South Africa, their example should return us to a focus on the traditional belief in the healing power and therapeutic value of art and artefact. We need to be both more respectful and nurturing if we are to develop a successful version of the practice of art therapy in South Africa. (Solomon, 2005: 12) Solomon’s analysis challenges assumptions that, she argues, are often made by those who have trained outside of Africa, for example in Europe or the USA, and who develop models, trainings and professionalisation processes. She comments that ‘indigenous people . . . here in Africa have

104 Backgrounds, histories and encounters   found Western colonial assumptions that these are countries with no effective healing practices of their own, problematic’ (2005: 7). Perspectives such as this show the complex interplay between history and present and offer insight into debates about ideas and practices connected to professional identity and the arts therapies as a discipline. The following offers another version of such developments. This interview is with expressive arts therapists and arts therapists involved in developing practice, supervision and creating professional identity in one of these particular ‘contexts’: Hong Kong, China. Lai has described the situation there in the following way: Different organizations began to invite therapists and educators to hold workshops locally. In the beginning, creative arts was regarded as one big genre before people began to understand and learn about the uniqueness of the individual modalities, including visual art therapy, music therapy, dramatherapy, movement and dance therapy and expressive arts therapy. (Lai, 2016: 21) Interview with Ka Kit Lai, Registered Expressive Arts Therapist, Registered Art Therapist, European Graduate School (EGS) Faculty member, director of Kunst EXA training; Amber Chan Hiu Wing, Expressive Arts Therapist, M.A.(EGS); Adeline Chan Ling Hin, US Registered Drama Therapist and Fontane Yiu, Expressive Arts Therapist MExpArtsTH (Hong Kong University) The situation twenty years ago involved people from Hong Kong returning here after training in the arts therapies overseas, mainly in the UK and USA. In the beginning it was hard, because the different settings and providers didn’t understand the arts therapies: for example, what the difference was between art, music or drama. Now the awareness is improving: this is the effect of even more people coming back to Hong Kong after training abroad and, also, of courses in the expressive arts being developed here in Hong Kong. So people are becoming more aware: ‘oh there is another choice’, when considering therapy. I trained in the USA and have been here in Hong Kong for over ten years. I have consistently worked with funders who provide continuity – for example the Cancer Fund, and NGOs that consistently fund my practice in different contexts, such as dramatherapy with people with mental health problems in centres and hospitals. YIU: I’m quite new to the feld. Some of my work is connected to a response to the increasing rate of pupil suicide in local schools. The Hong Kong Government is starting to pay more attention to the mental health of CHAN LING HIN:

‘Everything is ripe’ 105 pupils and providing more funding in this area: they hire more therapists in schools. I work with educational psychologists. In Hong Kong they have more status and bargaining power and the schools are clearer about what work they are doing, they can refer children to me: so I am doing this in partnership. In the future, I would still like to see such partnership, but also I am gathering more details of pupil and parent reactions to the expressive arts therapies and this can help educate settings such as schools about what we can offer. CHAN HIU WING: Usually, from my experience, social workers are an entry point to introduce arts therapies into settings. We attend seminars and conferences to educate social workers and to develop work together. In Hong Kong usually our work is supported by independent or project funding, so we might suggest to social workers that we write a proposal together. Also from my experience, social workers have a particular language to describe how the people they work with change: but we have our own language and ways of understanding change – for example, in projective work with clay where clients engage with their self-image. Generally, social workers or parents of pupils in schools fnd diffculties in understanding these ways of seeing change: we need to educate those in Hong Kong more about our perspectives and language. The arts and expressive arts therapists have associations here. They are working together to see if, with the very broad title of ‘creative arts therapists’, there can be registration recognised by the Hong Kong Government: this is being developed. YIU: The models of training are not yet refecting the particular, different Hong Kong context. I think this is our generation’s duty: to understand more fully how the arts therapies relate to Hong Kong settings and to use this in developing more public education about the arts therapies. CHAN LING HIN: After training in the USA, my experience of such a difference is that many Chinese clients don’t want to take opportunities in groups to share. It’s about taking space – some are very silent, but experiencing something powerful. I think there’s a different attitude to having and taking individual space. People are more used to speaking in groups when an authority fgure asks you directly and feel it’s better not to respond if you’re not individually asked. LAI: When I supervise therapists, for example if we are looking at a therapist’s relationship to empathy with clients: – I draw on Laozi’s and Zhuangzi’s text to introduce text and ideas from Tao – combining this with art, drama and movement and we see how it relates to the issue – we may understand empathy from art-based processes and refection on Taoist text. It’s about dialogues: I trained with the European Graduate School, highly phenomenological, with a focus on Heidegger and Merleau-Ponty. So we explore also Merleau-Ponty and Taoism. MerleauPonty talks about the fesh of the world, so the ontology concerns the outside and inside – and that is very Eastern thinking. Heidegger translated chapters of the Tao Te Ching or The Zhuangzi, so his later work is

106 Backgrounds, histories and encounters   much infuenced by Laozi. We try to understand what is the connection between such concepts. Sometimes at the beginning of the session and sometimes at the end, I would read text from the Tao Te Ching and develop an art-based response to the text, thinking about how to be a therapist in the local Hong Kong context. CHAN HIU WING: Arts therapists raising awareness together can be richer. Continuing to do this in Hong Kong will help make clear what people in Hong Kong can expect and help the arts therapies reach different clients here in hospitals, the community and schools. LAI: After training overseas we try to be culturally sensitive when we return. We begin slowly to develop a proper understanding of what we are doing. After another ten years, for example, we will have local practitioners trained by us: the second or third generation of therapists, really starting to understand the complexities of Hong Kong clients and how they relate to the arts therapies here. I did my practicum in Canada and was aware of the differences in the clients here – dealing with the different family systems, professional and funding structures. The new generations are developing a style, or way of approaching the arts therapies, that could work for local people. By ‘style’ I mean facilitating that is truly developed from the inside. After years learning from overseas in a different environment, slowly something emerges. For myself I think ffteen years ago I worked very differently. It takes time to create dialogue with contexts and why we look forward to developing local training that can be combined with overseas perspectives: to nurture the next generations of therapists. This illuminates how the three interconnected elements are taking different rhythms and forms globally. In this living snapshot of the development of the arts therapies in early twenty-first-century Hong Kong, we can see themes from the previous two chapters: of emerging clarity of aims and impact, of the need to articulate and differentiate language and process from other professions and the complexities of international and localised relationships to identity and provision. Here we can see the Hong Kong context creating its own version of the relationships between training; arts therapists beginning to practice; and the formation of professional organisations. An impetus for new understandings of the arts therapies is emerging through dialogue and exchange between therapists and clients and the ways in which localised situations create new opportunities and needs for innovation in nurturing a future in Hong Kong.

Conclusion We’ve seen, then, the ways in which the ground was ready for the arts therapies to grow. Black Mountain College in Chapter 8 showed some of the ways in which the climate for the arts therapies was forming. There were many other places and occasions in the twentieth century when people,

‘Everything is ripe’ 107 ideas and practices came together: we have seen examples from Nigeria, Colombia, India, North America, England, Japan and China. The opening speeches from the Conference of the Society for Music Therapy and Remedial Music in London in 1960 illustrate the kind of transitions which occurred when the arts therapies were moving from being supportive, recreational and occupational adjuncts, to seeing themselves, and being seen, as a primary mode of therapy. As Waller has described, ‘in any discipline, ideas have been in circulation for some time, but at certain points in history they get taken up, spread and a new discipline develops’ (1998: 77). I said earlier that the 1960 speeches represent many other meetings in the 1950s and 1960s when the arts therapies were emerging in their own right. By including the illustrations from Japan, Brazil and Hong Kong, we can see that such processes have been, and are, at work in different countries at different times. Chapters 8 and 9 have also illustrated the complex ways in which histories of oppression, power, regulation and protection interact and are present in contemporary development of our concepts of the arts, therapy and professional identity. I’ve also shown how thinking and ways of working became ever more articulate, and the position of the arts therapies more consolidated, by comparing in this chapter the 1960 speeches with later defnitions made at national and international levels as part of the process of the development and establishing of the arts therapies.

ten

Art and science: the rise of the medical model and the shadow of logic Introduction: opposites attracting? As we have seen earlier in Part III, and as numerous texts on the arts therapies have pointed out, the twentieth century saw a dramatic increase in the presence of the arts in organisations or institutions which were involved in healthcare in many countries. This is followed by an increase in the arts as a mode of intervention in the recovery and maintenance of health, or in the treatment of ill-health. In parallel with this, Bourne and Ekstrand (1985) describe the emergence of nineteenth- and twentieth-century psychology as marking a shift in many cultures: ‘Before the nineteenth century our curiosity about ourselves was largely speculative, yielding few conclusions that all could agree on’ (1985: 14). They note the emergence of what is described as ‘scientifc psychology’, as scholars trained in medicine and allied sciences developed an approach: ‘In place of speculation came evidence based on observation . . . The scientifc method offered a means for a real breakthrough in our understanding of human behaviour’ (1985: 14). Some arts therapists, as we have seen, question this understanding, arguing that in some cultures there is both a sense of historical continuity and of dialogue between the arts and healing. They challenge the simple division between ‘speculation’ and ‘science’ and assumptions about ‘evidence’ and ‘scientifc method’. A number of arts therapists point to tension or diffculty which often refect the relationship between arts practised in what some see as a science-oriented environment. British art therapist Edwards (1989), for example, has written of art and science in relation to the question of effcacy: When considering the problem of developing an appropriate methodology for evaluating art therapy it is necessary to acknowledge that while art therapists in general feel more comfortable with ideas and influences drawn from the humanities, it is within a world very largely dominated by science that we must live and work. It is from science that traditional forms of psychiatric treatment draw their authority and power, and it is with these forms 108



  Art and science 109 of treatment and the ideology that accompanies them that art therapists must find ways of co-existing. (Edwards, 1989: 173) Brazilian music therapists, note, similarly: In a scientific context there are some resistances related to new information, the attachment to the accepted structures. Indeed there is not always an understanding about the resources and the nature of this profession that explores, once more and in an innovative way, musical-sonorous elements. (Smith, 2003: 2; Music Therapy in Brazil website)

Kinds of dialogue There are different responses within the arts therapies to this issue. One approach involves the arts therapies entering into dialogue with traditional modes of medical provision and care and their frameworks of understanding and accounting for change as described by Bourne and Ekstrand. This, in itself, involves challenge, innovation and experimentation. Many speak of a mutual challenge involved in this assimilation. On the one hand, aspects of the health systems and users are challenged by the presence of the arts therapies. Some speak of changes in the systems, ideas and understandings at work within existing health provision as they respond to the presence of the arts therapies. On the other hand, the arts therapies are challenged to fnd languages, ways of working and concepts which speak to, and can learn from, existing modes of working. Areas include the way the arts therapies connect to the general provision of services for clients, how arts therapists communicate and work within multidisciplinary teams and the evaluation of client change in relation to existing systems and procedures. As the chapters in Part III reveal, the relationships between the arts, culture, healing and health is much contested. What is clear from the literature is that there is a burgeoning degree of enquiry into the diversity of this arena: from the broad scope contained in the Journal of Multidisciplinary Healthcare’s review of research from Nigeria to Brazil on the use of drawings to explore patients’ perceptions of their illness (Cheung et al., 2016) to the very specifc, such as the Journal of Dentistry’s (Tehran, Iran) enquiry involving 88 dentistry students on the effects of music practice on anxiety and depression of Iranian dental students (Ghasemi et al., 2017). Other examples of this diversity of domains include Bolwerk et al.’s (2014) research concerning how visual art production and cognitive art evaluation may have different effects on the functional interplay of the brain’s default mode network: Research on visual art has focused on its psychological and physiological effects, mostly in clinical populations.

110 Backgrounds, histories and encounters   It has shown that visual art interventions have stabilizing effects on the individual by reducing distress, increasing self-reflection and self-awareness, altering behaviour and thinking patterns, and also by normalizing heart rate, blood pressure, or even cortisol levels. The extent to which visual art may also affect the functional neuroanatomy of the healthy human brain remains an open question. (Bolwerk et al., 2014: 1) Bolwerk et al. used functional magnetic resonance imaging or functional MRI (fMRI), which measures brain activity by detecting changes associated with blood flow, of 28 post-retirement adults comparing a ‘visual art production’ group of 14 participants actively creating work in an art class with a ‘cognitive art evaluation’ group of 14 participants who cognitively evaluated artwork in the Art Education Department of the Nuremberg Museum (Germany). Research is reaching into many different societies, disciplines and traditions of knowledge. Looking across such different contexts and areas of enquiry, is it possible, or desirable, to create bridges between these different domains? Many excellent lines of communication between the arts therapies and other disciplines exist, and the field abounds with conferences that bear witness to the development of commonalities in understanding between major health service providers and the arts therapies. However, the relationship between the arts therapies and the existing models and practices of healthcare has been, and still is, a complex one. Gilroy and Lee, for example, discuss whether research that ‘asks “What is the effect of this specific kind of art therapy/music therapy intervention with this particular client group?”’ can be conducted through the standardised procedures of experimental psychology and the medical model (Gilroy and Lee, 1995: 8). It could be said that such concerns about efficacy are bound to be the case with any emergent or developing discipline. However, I think this is too general a stance to take. Whatever the state of dialogue, integration or assimilation, it is interesting to look at what is particular about people’s experiences of the developing relationship, or struggle, between existing systems of health provision and the arts therapies. Cornish (2013) situates parallel issues concerning models of practice, the availability of the arts therapies to clients and socio-politicoeconomic influences, commenting on Gilroy (2006). She cites a child and adolescent psychiatrist, Timimi, working in Child and Adolescent Mental Health Services, who emphasises neo-liberalism’s failings and how: beliefs and practices around children and families are shaped, [and conceptualised] by economic, political and cultural pressures (which) facilitate the rapid growth of child psychiatric diagnosis and the tendency to deal with aberrant behaviour or emotions in children through technical – particularly pharmaceutical – interventions. (Timimi, 2010: 686, cited in Cornish, 2013: 30)



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Cornish connects this to what she describes as ‘the strictures, structures and mores of prevalent government, and other powerful bodies, such as medicine and the pharmacological industry’(2013: 30). Within this she notes a tension which might result in the limiting of the complexity and diversity of art therapy: it is important to acknowledge the biased evidence-based practice paradigm and influence on policy formation and implementation on how Art Therapy proceeds with research in healthcare, as highlighted by Gilroy (2006; 2011). Gilroy concludes that ‘while Evidence Based Practice could be of enormous benefit to every aspect of state based provision – including art therapy – its values and systems could also inhibit the development of evidence appropriate to different practices, services and settings’ (2006: 7). (Cornish, 2013: 26–7) Sajnani et al. parallel such tensions in their analysis, they ‘call into question’ the: professionalization of care and the neoliberal values that position therapists as providers and participants as clients or consumers. In many ways, we are caught in a tension where we need to inhabit and account for our identities as arts therapists while also calling the norms that get attached to this identity into question. One example of this . . . is when we seek to justify our practice within a medical paradigm alone. Our skills with supporting personal and social change through a nuanced understanding of aesthetic and relational processes are valuable across contexts though our roles as mental health professionals (i.e. therapists) might need to be less pronounced. (Sajnani et al., 2017: 35) I especially want to pay attention here to some of the earlier comments about the nature of the challenge of the meeting between areas often seen, within the mainstream provision for health services, as unconnected – arts and healthcare. What are the natures of these relationships? Skaife (1995) and Wald (1999), for example, have both discussed the arts therapies in terms of their political nature as ‘radical and subversive’ (Wald, 1999: 11), and claim that their inherent potential is to challenge the status quo rather than to ‘induce conformity’. This contrasts with the more conciliatory position of music therapist Pavlicevic. She sees the relationship in terms of, ‘A rich tradition . . . [that] exists in allied fields – such as psychiatry, psychology, psychotherapy, neurology, musical aesthetics and musical analysis – and music therapists need to be confident about crossing the great divides,

112 Backgrounds, histories and encounters   building bridges and venturing into the unfamiliar’ (Pavlicevic, 1995: 64). I want to make two points about this. One is that there are systems of health at work, in both Western and in non-Western cultures, that do not rely on the medical model referred to by Bourne and Ekstrand or Gilroy and Lee. A number of authors refer to ‘the increasingly plural nature of healthcare’ (Budd and Sharma, 1994: 2). Other modes and ways of working were, and are, operating alongside the medical model. These include areas such as private practice, alternative health practices or education. Writers such as anthropologist Douglas have said, ‘The United States and the United Kingdom are two industrial nations which have inherited and share the same medical system’ (Douglas, 1994: 35). She says that industrial societies tend to draw individuals out of their primordial contexts of loyalty and support and ‘strands them’ in illness, isolating them in a system that looks at separation rather than connection (Douglas, 1994: 40). She typifies this separateness as one in which medicine is split off from religion, psychic troubles from bodily ones and different parts of the body split off to different specialists. I want to parallel this with Halley (1988), who says that there are certain characteristics that often occur in particular cultural contexts. He links creative movements as a response to people feeling stripped of their vitality, spirituality and emotionality – art is here a response to alienation, to what he calls a mechanised, repressed world: The post war period attributed to modernism a vanguard, heroic role, not in the political sense, but in the sense that it claimed that art was capable of reuniting humans with some lost essence and that art was able, as well, to release hidden, heretofore unaccomplished potentialities in the human being. (Halley, 1988, quoted in Harrison and Wood, 1992: 1074) He places this in the context of a further trend in the arts in areas such as the mass media and advertising. This change refects the ‘post-industrial concerns’ of manipulating what exists rather than creating new forms: ‘wilderness is bracketed by law, while tribal and folk modes of social organization have been almost completely assimilated (there remains only the diffcult question of the unconscious)’ (Halley, in Harrison and Wood, 1992: 173). Halley cites as of central concern those areas referred to by Foucault in his description of contemporary culture as ‘a place in which the technologies of surveillance, normalisation, and categorisation have ever broadening control over social life’ (Halley, in Harrison and Wood, 1992: 1074). He urges the need for artists to engage with, and counteract, this regimentation. The points made by Douglas, Halley and Foucault about culture, health and the arts are extremely relevant for arts therapists and clients in arts therapy, as they are for other artists.



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Many arts therapists would find this notion sympathetic: of the arts being modes of expression and creation that are set against regimentation. They would, similarly, echo Douglas’s concerns about the isolation and separation of the client into ‘segments’ to be treated. There is a need to find expression through the arts that is not to do with conformity and imitation of a norm, but to find a voice that is individual or situated in someone’s contextual, personally owned community. In addition, the arts therapies are very much about enabling embodied connection and relationship: between client and therapist and art form, and in the context of groups, the development of relationships between people. Art therapist Huss, in her work with ‘impoverished, marginalized, indigenous Bedouin women in Israel’ (2016: 85), challenges what she locates as a norm in much of arts therapies’ ways of engaging such connection and relationship. The approach she represents offers another important facet concerning the arts, therapy and ‘connectedness’. She argues that ‘the high social context is often left out of projective and phenomenological art analyses’ and that a ‘prism’ that engages with such relationships is vital as client experiences brought to the arts in the arts therapy ‘often emerge from a difficult social context’ (2016: 90). Huss and her clients explore the interconnectedness of their situation and the direction for therapy as situated in processes such as how ‘images reveal the power relations within the social system’ (2016: 84–5). In one client’s experience Huss describes an image as ‘a woman drew a tree (subject) with branches flying in the wind (background)’ (see Figure 10.1).

Figure 10.1 ‘a woman drew a tree . . . with branches fying in the wind’ (Huss, 2016:88)

114 Backgrounds, histories and encounters   The client describes the image in the following way: ‘My drawing gives me a feeling of my life: I am standing, thank God, and I am like the tree because I am trying to be strong and connected to the ground although my branches feel the wind’ (2016: 88). Huss, as art therapist, reflects on it as revealing: ‘the experience of the woman as a tree, inside the “wind” of her social reality, which is experienced as a storm against which she must struggle’ (2016: 88). Here the client and therapist see the relationship between image, client and therapist as part of an exploration of ‘the “wind” of poverty and lack of resources’ and a ‘depleting social context’ which is different from analysing the ‘tree’ through dynamic processes alone ‘as a decontextualized projected self’ (2016: 88). Many arts therapists would cite such integration and contextualisation as key to their practice: treating the client as a whole, rather than separating off feeling from physical illness, for example, and locating them, and the experiences they bring, in their culture and community. However, as we have seen earlier in this chapter, tensions are cited by some arts therapists working in the context of institutions, and institutionalised attitudes within healthcare, and these can be experienced by therapists and clients as ‘segmented’ and isolated in the ways that Douglas, Halley and Foucault describe. A part of this process can be seen in terms of the different ‘worlds’ or domains that the arts therapist connects with. These are both where the potential of the arts therapies lies, in bringing connection between art making and healing contexts, but also where tensions can exist. Peters, in writing about sharing responsibility for patient care, has pointed to the potential for tension between different professions in areas such as referral, treatment plans and collaboration regarding ‘discourse about health . . . [and] different languages in healthcare’ (Peters, 1994: 189). Reason echoes this: ‘Clinicians from different disciplines clash because while they may agree about what the patient needs, they interpret those needs through different frameworks [with] . . . different assumptions about what an intervention may do’ (Reason, 1991). Peters points to the importance of a client-centred approach. This involves analysing working practices, the discussion of theory and practice, resource allocation, referral procedures and, crucially, the understanding of different clinical models and languages to encourage positive interdisciplinary practice and interprofessional work in healthcare acting in the individual client’s interest to achieve ‘congruence, trust, respect’ (Peters, 1994: 179). Others have analysed the ways in which various systems of health and growth connect to arts and arts-related processes. Rappaport, for example, creates connections between recent ideas and developments concerning mindfulness in health provision, experiences in the arts and relationships to ‘sacred’ objects or healing rituals in many cultures (2014: 15). McNiff talks about the importance of what he calls ‘artistic knowing and creative experimentation’ in response to the preponderance, as he sees it, of areas such as the analysis of numerical data and behavioural science research in some institutional contexts. He says, ‘I do not in any way oppose science. I am suggesting a partnership identifying areas of common concern with



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“scientific research” distinguishing creative objects and processes that require new ways of understanding’ (McNiff, 1998: 13).

Shadow of logic? Warner has spoken of a continuing, deep and unexamined commitment to an idea of reason as distinct from the imagination that ‘may set up in itself a false opposition between the methods the mind uses to gain and apply knowledge’ (Warner, 1996: 14). She recalls a conversation with Edmund White concerning the need for multiple systems of enquiry into meaning, many-faceted analyses and representations on consciousness and creation to ‘enrich the languages by which we know ourselves and the world, expand syntax and give us more to grow in – a broader vocabulary’ (Warner, 1996: 16). It’s interesting to think of the period of the early development of the arts therapies in many countries and how unusual it must have been for psychiatric hospitals that used drugs as a primary mode of treatment to also have a room where patients painted, made music or danced. Are these incompatible, or are they an example of the multifaceted analysis spoken of by Warner and White? Are the arts a challenge to concepts such as the medical model? Are they having the radical energy drawn from them by producing a language which speaks to the ‘medical’ but which teaches the arts to lie? Is radical energy being made to talk numbers and become part of the world of bureaucratic isolates which Douglas speaks of? Is the individual who dances in the DMT studio being forced through an act of seemingly individual expression to conform as the therapy provides ‘a corrective experience that helps a person behave in a more socially appropriate, adequate and adaptive way’ (Bourne and Ekstrand, 1985: 455)? I would argue that the answer to all these questions is ‘no’, as we will see. However, they illustrate the tensions and difficulties described earlier. But what can the relationship be between the arts therapies and healthcare systems? Johnson, in my view rightly, sums this up in the following way: ‘Neither . . . trying to clone ourselves as psychiatrists or analysts, nor seeking our culture’s shadow side of the tribal shaman, seem satisfactory . . . (but) then what are we to do?’ (Johnson, 1999: 115). He looks to a vision of arts therapist ‘as embodying both science and soul, logic and magic’ (Johnson, 1999: 115). For me, it is in this way that the arts therapies need not be seen as either art or science. The arts therapies are a product of a link made in diverse ways within different societies and cultures and in response to a divide present in many societies’ cultural concepts and practices. They are a sign of a vital connection between areas often experienced as divided. They should not be split by their conception being between ‘art’ and ‘science’ parents whose artist and scientist families often can seem suspicious of each other. Some, such as Gregory and Garner, look towards a similar mutuality: ‘Art therapy, as its name implies, is a combination of art and science’ (Gregory and Garner, 2000: 1). Young says that art therapy has grown up in the

116 Backgrounds, histories and encounters   ‘shadow of the medical model’ (Young, 1992). Others have said that, as a discipline, ‘art therapy has uniquely combined art and science, providing a model for the interaction between two disciplines often viewed as separate’ (Gregory and Garner, 2000: 1). Vick calls this a ‘false dichotomy’ arguing that ‘while the early practice of art therapy did have a strong medical model orientation . . . a far wider range of theoretical positions have emerged’ (2016: 831). Stuckey and Nobel (2010), in their review of literature on the arts and health outcomes, cite Yorks and Kasl on ‘expressive ways of knowing’ (2006: 43), in their conclusion that: Use of the arts in healing does not contradict the medical view in bringing emotional, somatic, artistic, and spiritual dimensions to learning. Rather, it complements the biomedical view by focusing on not only sickness and symptoms themselves but the holistic nature of the person. When people are invited to work with creative and artistic processes that affect more than their identity with illness, they are more able to ‘create congruence between their affective states and their conceptual sense making’ (Yorks and Kasl, 2006: 53). (Stuckey and Nobel, 2010: 261) Pavlicevic expresses a need I would echo: to obtain a ‘clear understanding of what it is that makes our work unique, different from and similar to that of other allied professions’ (Pavlicevic, 1995: 64). Langham says that it is important not to put a frame around the profession of art therapy, or ‘to rigidly define its position in relation to either the art or the medical establishments. It is in a fluid and radical position between the two’ (Lanham, 1989: 21). Both Johnson and Young use the term ‘shadow’ in describing the relationship between the arts therapies and medical contexts. I think one of the processes reflected in their use of this term can be linked to Jung’s representation of the shadow: ‘The shadow as we know, usually presents a fundamental contrast to the conscious personality. This contrast is the prerequisite for the difference of potential from which psychic energy arises. Without it the necessary tension would be lacking’ (Jung, 1955, par 707, 1997: 168). The connection of these two areas, Jung argues, brings about full potential: ‘the resolution of opposites is always an “energic process”’ (Jung, 1955, par 705, 1997: 166). Perhaps we could argue that in the current development of the arts therapies a meeting is occurring between areas often split into opposites – art and science. This is part of the tension often experienced by arts therapists, and by clients in some settings in relation to issues such as medical model practice. It is important to see this potential split as expressing an opportunity. Looked at in relation to Jung’s ideas of potential, the necessary creativity and imprecision of improvisation and the arts offers an energetic challenge within settings that can often be experienced as at



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odds with these qualities. It is in encountering this contrast and in looking for balance that the arts therapies are radical.

Conclusion: revolution or collusion? The literature argues that the arts therapies came into existence in part as a recognition of needs and potentials between domains that, by the twentieth century, were often separated: the arts, play, healthcare, ritual and education (Landy, 2001; Seymour, 2009). Their emergence, or re-emergence, has come about because of unrealised possibilities between different disciplines – created within the creative, potential space between them. Their emergence and potency as therapy did not arise within a single discipline, but from the potential of the interdisciplinary: between areas such as theatre, music, education and health. This way of looking at the feld suggests that the vitality and relevance of arts therapies are powered by an interdisciplinary, creative dynamic. Corazza and Agnoli’s review of the developing understanding of creativity positions it as ‘a complex process’, where multidimensionality or interaction between different disciplines’ involves ‘cognitive, dispositional, emotional, social, and cultural elements’ with the ‘success of the interaction’ resting in the emergence of the ‘novel and valuable’ (2016: 4). The novel and valuable, they argue, ‘derive from the projection of the new idea onto existing knowledge’ (2016: 4). Interdisciplinarity has been seen to be of value in offering potentials for innovation in philosophy, theory and praxis (Jacobs and Frickel, 2009): in the creation of insight in specifc felds but also enabling the emergence and development of new felds. The arts therapies are hybrid and their development is a creative response to a gap and potential arising from changes, interactions and unease in the felds of health, medicine, psychotherapy, education and the arts. It is in this way that the potentials of the arts therapies should be seen – that a mutual change is occurring between ‘arts’ and ‘science’: one that involves discovering more about the other, the breaking down of distinctions and oppositions and the creation of dialogues, and of respect for diversity. Crucial to this is an understanding of ‘what works’ for clients. The complexity of this understanding will be a thread through subsequent chapters, focused on especially in Chapter 17 on evidence and effcacy. However, I want to gain inspiration from a video artist talking about survival, evolution and extinction: about the avant-garde and the mainstream. Torres talks about the challenges of video art to mainstream art, about how, in cultural, political and economic spheres, ‘stasis’ is a ‘guarantee of death’. She describes change, by contrast, as a ‘by-product of curiosity, the desire for knowledge and a clear indication of creative vitality’ (Torres, 1996: 209). For the arts therapies, the art of the possible is the project still being realised – of the curiosity and vitality of understanding itself as it comes into contact with clients in different settings and different clinical situations. In acknowledging and drawing energy from the apparently oppositional

118 Backgrounds, histories and encounters   worlds of art and science, the arts therapies are still developing, discovering: the changes in healthcare they offer to clients are the by-product of deep curiosity. The creative energy represented by the early connections, the hopes of Gruhn, featured in Chapter 9, for example, are still present in the pioneering curiosities and discoveries in arts therapies’ clinical practice, research and theory. The nature of these findings and discoveries form the backbone of the rest of this book.

PART IV

Agents of trAnsformAtion: Arts, therApy, plAy i think art therapists are naturally creative thinkers with great empathy . . . this is a very exciting time to explore what digital technology has to offer art therapy because we are in the moment of massive digital influence affecting all areas of our culture . . . Developing research to articulate the clinical and theoretical perspectives on digital media can also deepen our understanding of the many challenges, limitations, and benefits of working with a medium that is constantly evolving. interview with Choe, from Chapter 11, page 139

eleven

the arts in the arts therapies Introduction: arts and therapy is being involved in the arts as necessary to humans as eating, sleeping or sex? some have argued that creativity is as essential to living, to well-being and to healthy fulflment as these activities. An absence of creativity in general, or through its particular expression in the arts, they assert, will result in ill-health. As we saw in part iii, the arts therapies ask questions about our need for, or use of, the arts in ways that connect to these ideas. is there a relationship between the arts and health? Can they add to the quality of life? is there a difference between generally participating in the arts, and using the arts as therapy in terms of maintaining health or dealing with difficulties? is there a danger that allying the arts to medicine destroys the heart of art making? how do different societies and cultures address these, or parallel, questions? the arts therapies have evolved particular ways of answering these questions about the arts. this chapter will explore these answers, as well as analysing ways in which the arts feature within the application of the arts therapies. some have criticised the arts therapies for merely using the art form as an extension of verbal therapeutic process. they say the image or dance becomes an adjunct, subordinate to words. seen in this way, art therapy can be psychotherapy with pictures as a ‘helping hand’, or dramatherapy can be cognitive behavioural therapy that contains some role-playing. the art form is an addition to the main activity, which is seen to be the verbal therapy. those criticising this position see it as a waste of the full potential of the arts therapies. there may be some practice where this subordination occurs; however, within most arts therapy practice this is not the case. many would argue that in arts therapy the two areas – arts and therapy – are intertwined and each changes the other. Arts therapies are not two disciplines joined for convenience; the term can be seen to mark a discovery of mutuality and of unique potential, as the last chapter proposed. one thing we can be sure of is that in the arts therapies clients and therapists alike are engaged in an art form within the therapy session. even if the client and therapist are not directly painting or moving within a single session, the opportunity for potential expression is implied and available – it 120



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is a constant. Beyond this basic assumption, though, matters become more complex. these complexities relate to the variety of art forms and ideas within the arts therapies. firstly, i want to identify some questions that will help explore this diversity. Does the particular arts modality, drama, for example, or dance, make a difference to the experience of the client and therapist? even within the individual art form there are various specialised or specific ways of working or techniques. in exploring material in art therapy or dance movement therapy, for example, the therapist and client may normally engage in a particular aspect of the individual art form. in art therapy a client might engage in painting, clay work or collage, for example. Does it make any difference to a client whether they use clay or collage in art therapy, objects to depict a story, or perform a script in dramatherapy, or whether they play an instrument, or listen to a recording in music therapy? this chapter will look at the arts therapies from the perspective of the arts and will look at these questions to try to understand the arts element within the arts therapies.

Situating the arts in the arts therapies in discussing the relationships between dance, dance therapy, culture and individual in senegal and guinea, monteiro and Wall (2011) draw connections between body, expression, community and experience. they argue that ‘movements in dance’ can be seen as symbols and that: members of a society may understand that these symbols are intended to represent experiences and give meaning to an individual’s external and psychic world. specifically, the nonverbal behavior of dance is an integral component to . . . meaning (and) provides the interface between the spirit realm, the individual and group. (Monteiro and Wall, 2011: 238) here dance is seen as a way of expressing, communicating, connecting and as a means of meaning making within a particular situation or context. A client’s movements and the physical interaction between therapist and client, for example, can also be seen in this way. As Callaghan says, ‘people’s bodies and ways of moving express individual, family and cultural movement patterns, which are manifestations of the individual, family and cultural psyche’ (Callaghan, 1996: 256). here, the emphasis is upon movement that emphasises feelings expressed in, and through, the body and locates this within the dynamics between individual, community and culture. this quality of the arts can occur through the way individuals express themselves in dance movement; the way clients physically interact with each other and with the therapist. researchers such as Chang (2015), hanna (1990) and Alrazain, et al. (2018) problematise aspects of this relationship between the arts and communication in therapy in both

122 Agents of transformation   beginning, and developing, practice with clients. hanna notes that there can be no assumption of a universal norm in dance and movement, for example, or that the client and therapist share perspectives. from first contact onwards she advocates the need for therapist to work towards a ‘cultural awareness’ of the client’s relationships to the arts therapy process and language, as an assumption of commonality ‘creates barriers to healing in addition to placing new stress upon the client’(1990: 118). she argues that the dance movement therapist must be aware in particular ways: ‘effective therapy requires an understanding of the cultural and ecological patterns governing a client’s life, the different concepts of mind, body, parts, time, space, effort, color, texture, and other properties found in everyday life and the arts, as well as what movement is done where, when, how, and with and to whom’ (hanna, 1990: 118). Drawing on Alyami (2009), Alrazain et al. discuss the complexity not only of such ‘awareness’, but of the ways in which this interrogates held norms in practice: ‘art therapy in the Arab world needs to be designed in line with social, cultural and religious customs of the communities’ (2018: 70). they note how, for example, the cultural and religious situation in the Kingdom of saudi Arabia (KsA) presents challenges for the growth of arts therapies in the country. Activities such as dancing and playing instruments are not allowed to be practised in schools . . . as a result the use of dance movement therapy, music therapy and, to an extent, dramatherapy, would raise questions about the exhibition of the body in a prohibited manner. similarly the limitations on artistic depiction constrain the activities which can be used in art therapy. (Alrazain et al., 2018: 70) though the saudi ministry of health has ‘approved’ art therapy as a specialised field of psychotherapy, in 2018 research revealed ‘no art therapists working in schools’ (2018: 70). the therapists describe their work and its relationship to arts and society in terms of absence and presence: ‘Dance and music were not used due to the cultural context . . . instead, rhythmic clapping and clicking were included . . . when art work was used, the children were asked to engage with tasks that did not include human or animal entities in accordance with the islamic stricture used in the KsA against the representation of living beings’ (2018: 73). some approaches to research connected to the arts therapies use the concept of exploration and dialogue between different situated cultural arts forms and the arts therapies. hämäläinen et al. (2017), for example, conducted research into ‘health-bringing potentials’ and yoik, a sami vocal music tradition from circumpolar fennoscandia. they describe yoik as being comparable with singing because both are vocal expressions, but they ‘differ in important aspects such as yoik’s referential symbolic function, i.e. that yoik refers to and symbolises an object/subject musically and thus,



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according to yoikers, always expresses something directly with its melodic and rhythmic organisation’ (hämäläinen et al., 2017: 2). yoik is situated as ‘a very significant cultural means of communicating’ within sami culture, with the research exploring sami perceptions and experiences. one of the types of yoik, for example, is the ‘personal yoik’, it: is given away from one person to another, often from a parent/grandparent to a child as an expression of love and affiliation. the yoiker expresses his/her perception/impression of the character of the other person in the melodic and rhythmic organisation of the yoik, as well as in the vocal performance. the yoiker may or may not use a few words, such as the person’s name. A personal yoik is usually a positive acknowledgement of a person, a personal attribute that accompanies the person throughout life. (Hämäläinen et al., 2017: 2) individuals talked about how the personal yoik is used to greet, lift up and honour a person, but also to recall a person not present: one participant reporting that ‘When you think about someone or miss a person and you yoik that person, it is as if the person is there with you’ (2017: 2). the research revealed how the yoik related to experiences of what the researchers describe as ‘processing’ loss. participants explained: When a close relative died it was very difficult, but i kept on yoiking this person’s yoik . . . hour after hour . . . and gradually . . . i felt i came through the worst peak of the sorrow. When i’m really angry i yoik a special yoik so everybody can hear it and know i’m angry! (Hämäläinen et al., 2017) When the participants were asked to summarise what yoik means to them in one word or a short sentence, many of them said: ‘yoik is communication, a way of remembering’ and ‘yoik is a connection to something beyond myself’ (2017: 2). hämäläinen et al. reflect on their findings in the following way: yoik does not necessarily have a conscious and outspoken purpose. to search for its function and potentially health-bringing potential implies looking for what is not necessarily said out loud. still, based on the findings of this study, it seems that yoik may be good for people’s health as a means of emotion management and self-regulation. yoik may give a sense of belonging for many sami people. this study indicates that yoik may have an underresearched potential as an intervention in culturally sensitive

124 Agents of transformation   healthcare and health promotion work that deserves to be acknowledged and further investigated. (Hämäläinen et al., 2017: 2) here the emphasis is on dialogue between researcher and participants in locating through exploration and questioning the ways the individuals and the art form communicate their experiences and views: acknowledging the complexity of asking about something that might not, in everyday life, be conscious or verbalised. Chang (2015) notes the importance of such ‘intercultural exploration’ in developing client–therapist contact and relationships: advocating the need for the arts therapist to be able to reflect upon ‘personal identity’ work and art form, locating their own racial, ethnic and cultural selves. in this way they are better able to ‘meet’ the clients’ ‘own social and cultural contexts’ and to enable ‘creativity’ to be ‘addressed in a reciprocal, provisional and respectful manner that opens into interrogation and mutual exploration’ (2015: 305). research such as that undertaken by hämäläinen et al. (2017) and Chang (2015) seems a vital illustration of Chang’s conceptualisation of the importance of situated meaning in relation to the arts and different healing or health contexts.

Starting out most arts therapists attempt to identify the best routes for clients to engage in an art form within the therapy. this happens in different ways. some therapists will try to work in a relatively non-directive manner, allowing the client to discover materials within the therapy space. for example, an art therapist might invite a client to choose materials present within the art therapy room. A music therapist, similarly, might invite the client to work with instruments available in the room, and to follow the lead of the client’s choice of instrument and way of working. once the client makes a start, the therapist will attempt to be sensitive to the creative direction the client takes, as they discover ways of expressing themselves using the art form, or as they encounter creative frustrations. All arts therapy work within this approach, though, is rooted in the idea that the client discovers his or her own relationship to the art form and that creativity is accessible to all. this concept refects a cultural shift within many parts of many societies, summarised by tan and perleth as, Creativity in the twenty first century is fundamental to all . . . Creativity is no longer an asset of a few geniuses or artists. it is a potential of all. in line with open and broader understanding of creativity, (it) is conceptualised within the person’s . . . social-cultural and developmental milieu. (Tan and Perleth, 2015: 1–2)



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there would be no formal attempt to train or teach the client in the art form or expression. the basic assumption echoes that made by mcfee and Degge: Art is a principal means of communicating ideas and emotional meanings from one person to another, from one group to another, from one generation to another. When people have new experiences, they symbolise the experiences in an art form; they observe their art and then obtain new insights about their experiences. (McFee and Degge, 1977: 272) some arts therapists offer a structured introduction to the art form, helping clients to become familiar with using the media to express themselves. this is normally through a process of ‘warm-up’, whereby simple activities begin to provide access to the art form. this might be an invitation to make marks, or the therapist might offer a short series of exercises developing the client’s ability to play a role. the emphasis is not on teaching technique for the sake of learning alone, but on offering routes into the arts for the client to develop their relationship with the art form, space and relationship with the therapist: an entry into creativity and creative expression within the therapy. farokhi, for example, positions this as the client developing an awareness of an art form’s expressive potentials as it ‘stimulates an individual’s thoughts, emotions, beliefs, or ideas through the senses’ in the context of the developing therapeutic relationship (2011: 2089–90). such perspectives on clients starting therapy are effectively considered by music therapist pavlicevic as she describes the issue of ‘directive’ compared to ‘non-directive’ approaches in the development of what she calls the ‘musical space’ in her practice in south Africa between 1991 and 1994. she locates her choice of approach partly in the political tensions that existed at the time: ‘it must be remembered that these groups took place in south Africa during a very fraught political climate in which no-one was protected from the tensions dominating the country. for many these groups were an opportunity to “forget about our problems”’ (pavlicevic, 1995: 363). she records two comments made by clients in the initial stages of the group: ‘We need you to play with us so that you can provide the structure for the improvisation, because once you provide it we know that we can just relax and play inside it . . .’ ‘playing with you means that i am guided into new directions which i would not otherwise find on my own’. (Pavlicevic, 1995: 363) pavlicevic also talks about the musical silence that often marks the beginning of music therapy work, along with the initial improvisation with music that is made by a group. she says that key questions at this stage include how the improvisation begins, how the musical space is defined, formed and

126 Agents of transformation   controlled: ‘is it offered, grasped, taken?’ (pavlicevic, 1995: 362). the basic assumption is that the nature of the formation of this space consists of the relationships between participants and their initial experience of improvisation, their relationship to any instruments used, and their relationships with the therapist and each other. these elements are seen to contain the initial dynamics of the group, as well as expressing or connecting to personal issues for individual clients. she gives as an example an individual making the first sound, an ‘opening solo’: for example, this might be very loud, full, complex and busy. here other players might begin to feel superfluous, asking whether there is any space for them, any need? Can they make a relevant contribution? she says that such initial periods move the group towards areas such as feeling cohesive fairly quickly, or forming feelings of uncertainty and unpredictability. hence a soundscape is seen to express the relationships and issues within the forming group. the dilemma for pavlicevic is how to work with client requests or comments such as those quoted above: ‘by providing a musical structure within which the group improvises, rather than allowing for the space to unfold, i could be imposing and limiting the possibilities of musical spontaneity’ (pavlicevic, 1995: 363). she says that she sometimes works directly by offering structure, and at other times works in a more non-directive way by seeing how the group engage with the musical space without her providing a direction. some of her thinking about this important choice is present in her comment on the decision she made in this instance. she cites the political tensions, the general feelings of lack of safety, as well as the material from clients quoted above as relevant to her choice. in addition, the groups were relatively brief, normally six two-hour weekly sessions. she made the decision that her role was ‘to provide a facilitating environment within which people could be enabled to play as fully and freely as possible’, and that providing a musical structure ‘could be seen as enabling the group to get on with playing’. so, in this instance, pavlicevic shows us her thinking in deciding how to enable the group to ‘create and claim space’ in order to ‘play’. it is based on a number of factors including her perception of wider social issues and experiences of group members, especially concerning tension and safety, the length of the group and the nature of the clients and their comments (pavlicevic, 1995: 363). so, such entry into the arts space is a dynamic one, reflecting processes such as the relationship between therapist and client, or between clients in a group context. the initial relationship with the opportunities the arts space offers is seen as a communication between therapist and client. the decisions made at this time by the therapist, concerning issues such as being directive or non-directive in their approach, are a part of this encounter with initial meanings found in the therapy. some arts therapists, then, might introduce or suggest an activity or way of working which would aim to support the process of the therapeutic work. this is normally following the goal of assisting the client’s exploration of personal material in the therapy. this idea is that the arts experience is connected to the client’s engagement with emotional material, problematic



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issues or areas of potential development. Any suggestion about the use of the art form made by the therapist within such an approach is informed by their perception of the psychological or emotional needs of the client, or by an attempt to assist the process of the therapy. the therapist mostly tries to follow the client’s direction and needs. A music therapist, for example, says that she works without the notion of a conductor or director in the process; she never, for example, gives a beat to begin with: ‘We usually begin with a complete silence . . . before the first sound is heard; then anyone can begin as they like’ (Alvin, 1975: 14).

Therapeutic improvisation these examples also highlight one of the key ideas about the nature of the arts within much arts therapies practice. the route into the art form and expression is one that is based in improvisation. pitruzzella situates improvisation as a commonality in the arts therapies, linking it to a process of personal exploration: it is ‘the space in which people reveal themselves, through the mediation of the expressive language and actively search for new patterns and new meanings’ with the therapist and with others, if the therapy involves a group (2016b: 78). it would be unusual for an art therapist to give ‘lessons’ to the client in life drawing, for the music therapist to teach scales and fngering, the dance therapist to teach a dance form or for the dramatherapist to give direct training in a style of acting. this echoes some contemporary attitudes towards improvisation in the arts. for example, musician tang-Chun li, in ‘Who or What is making the music: music Creation in a machine Age’, defnes the act of composing by improvisation as, ‘to externalise the ideas and constructs of the mind, or mental maps, by performing some operations on some type(s) of sonic medium’ (li, 1999: 57). this improvisation can draw upon more formal forms such as harmonic series, chromatic scales, or can use a squeaking door or sequencers: the ‘roaring of speeding cars on a highway during a quiet night’ (li, 1999: 57). here the emphasis is upon the immediacy of creation, and of the individual’s drawing on materials, processes and participation to express or to communicate rather than to use the art form according to a prescribed tradition. li’s attitude towards creation and improvisation is similar to that in the arts process in much arts therapies practice. there can be an element of instruction, but this is usually done indirectly, as a background or support to the client’s encounter with the open space of the arts therapy, or the encounter with the arts therapy triangle of client–therapist–art form, as described in Chapters 3 and 17. the issue of whether someone is ‘good at’ the art form often enters into the client’s initial encounter with the arts therapy. Art therapist lanham describes this common occurrence: i frequently find myself saying to clients in art therapy words such as ‘it doesn’t matter if you can’t draw’. in doing

128 Agents of transformation   this i am attempting to help them move beyond some of the stereotyped views of art and artists held by our society, in particular the commonly held view by adults that if you are not ‘good at art’ then it is best not to try it. (Lanham, 1989: 18) for many clients the initial move to engagement with the art form is not so free. labels encountered in life, such as ‘not good at art’, ‘tone deaf’, ‘playing is for children’ or ‘shy’, are present, especially on first contemplating or engaging in the arts therapy space. this attitude is rooted in the division present in many societies between artists and non-artists: this disenfranchises people from feeling they have the capacity to use or express themselves through the arts. looked at in this way, a part of the arts therapists’ role is to assist the client in dealing with the barriers that society places around access to using the arts as makers rather than consumers, and dealing with labels such as ‘not good at art’ or ‘not an artist’. lanham says that, ‘We all know that these are not labels that need to be adhered to’ (1989: 18). this does not mean to say that skill or proficiency in expression or aesthetic considerations do not enter into the therapy. there is a difference between a belief that everyone can express themselves through the arts, and saying that the language or form does not matter. the difference is that in the arts therapies the client can engage in a relationship with the art form and process whereby they discover, challenge themselves, and develop this relationship within the space and with the therapist, rather than being taught a prescribed notion of how to express and what to express. skaife shows that choices over colour or form, over aesthetic considerations, are not seen in terms of learning or education about an art form, but rather as a part of the personal process within the therapy: the process of deciding whether to put red there or not in a picture, of taking the risk of losing the picture by restructuring the whole piece, creating a dull piece of work because of avoiding feeling, giving up on something because of feeling no good at it, all these things can be experienced and mastered with the aim of making an exciting piece of art work. Development of an aesthetic sense is part of the endeavour, without this there are no boundaries and so no precision. (Skaife, 2000: 115) here skaife neatly shows parallels between the ways in which someone’s relationship with creating in an arts therapy session can be seen as part of a personal process, rather than simply as a matter of skill. Within the therapy space the signifcance is often less on whether someone has a training in an art form and more on the ways in which the ‘dullness’ or aesthetic ‘risk’ take on meaning as part of the process in the therapy, as a part of the client’s feelings and relationships.



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in some situations, some arts therapists might work with the client to develop a greater proficiency in an aspect of the art form. this is not, though, to do with the therapist teaching the client a form of arts process, or language, according to a set notion of necessary music skills for music therapy, or dance movement language for dance movement therapy, for example. the client might wish, or need, to hone their capacity to use the medium in order to find the precision of expression they wish to engage with in expressing or exploring an aspect of their lives. the client might, alternatively, arrive at a greater dexterity, or develop the capacity to express themselves more effectively through their continuous use of the art form. Byrne has undertaken research in this area, and his conclusion was that competence emerged during the client’s course of art therapy ‘despite art therapists’ refusal to “teach” them how to make pictures’ (1995: 236). he considered areas such as the development of a vocabulary of images, the use of materials, and the capacity of the work to hold and communicate meaning for the client. in some circumstances, as we will see, the development of the client’s capacity to use the art form, or the level and the nature of his or her engagement might form a part of the process of change in the therapy. some arts therapists might offer therapy in a way that focuses on a particular aspect of their expressive form. for example, a dramatherapist might offer a role-play based group, or an art therapist might offer a series of sessions using group painting. here the clients might elect to attend this session, deciding for themselves that the form might be of interest or use. however, improvisation, rather than taught expressive methods or forms, remains at the core of all these approaches. in the early stages of therapy, then, the arts therapist attempts to identify with the client what the best routes to using an art form within the therapy can be for them. this concerns the form or language to be used, as well as the approach to establishing a relationship between the client, the therapist and the arts therapy space.

Creation of an arts space there should, though, be no assumption that ‘improvisational’ means careless or lacking in involvement. the relationship between arts processes, client and therapist in arts therapy is not casual, passive or incidental. it is not that of a listener to piped music in a supermarket, or of a passive encounter with images on a roadside advertising hoarding. the arts therapies encourage and depend on an intense engagement with an art form, with an intention that this will be a key factor in change within the client’s life. the client’s experience of the arts aspect of the arts therapy over the time of the therapy might vary enormously: from boredom, to rejection or a lack of inspiration, through to deep absorption. the client is not forced into this kind of engagement; the therapist does not coerce. however, the process, when seen as a whole, aims at an intimate, powerful meeting between the client’s life and the art form and process. the ways in which the arts offer

130 Agents of transformation   specifc routes to awareness and communication are made available to assist the client in their attempts to change. Artistic processes can occur in many different ways – some can happen within, and as a part of, everyday living. others can occur in extremely disruptive conditions, whether physical or emotional. for instance, graffiti art can be produced in the middle of urban noise with the constant threat of interruption, owing to the illegal nature of the situation the work is being created in. youths, for example, might be stopped by passers-by, or by police. other art has been created in situations of intense deprivation and disruption, in concentration camps or in internment, for example. Within many cultures, though, the creation of art, or engagement with artistic activity, is often set aside in a special place. As we’ve already seen, some arts therapists have drawn inspiration from children’s play, viewing it as a part of, or allied to, art making. this will be considered in more depth in Chapter 13. Whilst some forms of play happen alongside other, everyday activities, a number of analyses of play have pointed out that ‘deep’ or concentrated play can normally only occur in circumstances or situations which have specific qualities. Arts therapists attempt to create a space within the therapy room which is, in many ways, similar to that appropriate for deep play (see the player client box below). one of the best discussions of this is by Wood (2000) in her description of the art therapy studio. she stresses its role as a container, as a place which encourages absorption, and where play and mess can be tolerated. this provision of a space, whether in art, drama, music or dance, attempts to assist creativity: to maintain a fine balance between not seeming too controlled or contrived, whilst creating a consistent place where opportunities for spontaneity can occur. in some ways this might seem a paradox – a deliberately created place and time for spontaneity to occur! this, though, is something that the therapist tries to enable – a deliberate space for spontaneity. this spontaneity refers to artistic expression within the session, but is also central to the opportunities for therapeutic change which are crucial to the client’s use of the arts therapy.

The player client most arts therapists would have sympathy for Jung’s view that: All the works of man have their origin in creative imagination. What right then, have we to disparage fantasy? [it is] closely bound up with the tap-root of human and animal instinct. it has a surprising way of always coming out right in the end. the creative activity of imagination frees man from his bondage to the ‘nothing but’ and raises him to the status of



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one who plays. As schiller says, man is completely human only when he is at play. my aim is to bring about a psychic state in which my patient begins to experiment with his own nature – a state of fluidity, change, and growth where nothing is eternally fixed and hopelessly petrified. (Jung, 1997: 91) here Jung is talking of the basic aims of therapy. many arts therapists, no matter what framework of change they bring to their work, would agree that the arts therapist attempts to create a space where the client can be at play, and that this is seen to create a playful state – where, as Jung says, the client can experience themselves as capable of change and growth.

the practicalities of enabling this space to occur are not, however, based in a romantic notion of the artist in their ivory tower. they need to be as relevant to practice in a hospital, an inner-city playgroup or a refugee camp. regev and green-orlovich’s research into art therapists’ experiences in israeli schools revealed both positive and challenging experiences about space and art form in ways that help understand this aspect of practice: most therapists stated that there were often interruptions by various people coming into the room during a session, including educational staff and children who burst in or peeked in during therapy. noise from outside can also penetrate the room and vice versa. All of these factors may cause the client to feel that the therapeutic space is not protected . . . or make it harder to create a separation from the school space [and to maintain] a safe platform for clients to fulfil fantasies and express certain aspects of their personality. (Regev and Green-Orlovich, 2015: 15) this is compared to more positive experiences where ‘therapy rooms were relatively isolated, and clearly defined the separation between the therapeutic space and the educational (and) where there was a sufficient amount of art materials the therapist can do their work’ (2015: 53). the key factor concerns a necessary protection, given that in this creative space intimate, private material may emerge, enhancing the need for boundaries of privacy. simply put, the conditions allow the art work to emerge, they are suitable for the arts work to take place, and are safe for the client to create arts expressions that concern the issues they are bringing to therapy. there are basic assumptions regarding the nature of the requirements of space that are common across the arts therapies (see the Creative space box).

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The creative space the space needs to: have the clear boundaries of regular availability have consistency of relationship – that the therapist maintains a regular presence and responds in a consistent but flexible way remain uninterrupted by other activities, or others not part of the activity be private, not overlooked by casual passers-by or be overheard provide access to necessary materials be adequate to the task – not too small or large (e.g. a space which is too small might hinder dance work, a space which is too large might lead the client to feel overwhelmed and unable to concentrate).

the focus is on consistency, on privacy and being free from disruption to art making. in most circumstances regularity of time concerns a consistent slot each week. however, for some forms of arts therapy, such as art therapy’s open studio, this is slightly different. in this situation, an open art room is accessible for most of the day and an art therapist is in the space, available should the client wish to engage with them. these ‘basics’ are experienced in different ways, though. therapists and clients bring different expectations and associations. A number of practitioners write about how people’s experiences of space and creativity will affect the way they come into and use the arts therapy room. people used to creating in groups or large spaces may feel locked in by an individual therapy room – may find it a ‘restrictive, physical space’ (mcfee and Degge, 1977: 360). issues concerning the use of shared space and privacy often surface. for example, clients who have been raised in ‘structured . . . environments’ with ‘don’t touch’ attitudes towards the things around them, compared to those who were ‘allowed to open and shut, crawl through, handle and feel the surfaces of the things around them’, may bring different assumptions and engagements to the arts therapy space (mcfee and Degge, 1977: 264). other work reveals differences in terms of how contexts create the need for particular forms of relationship to emerge. nhlapo, described as a ‘community art counsellor’, talks about the context and creation of space within a refugee camp in south Africa: ‘temporary tents were white and clean but the insiders were damaged. i saw . . . men queuing for food, hungry . . . the children that we saw for the first time were uncontrollable. i felt sore when children told how their parents panicked in the rush to save them. We let the stories unfold, we held them the best way we could’ (nhlapo, quoted



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in Berman, 2010: 27). their description challenges many arts therapies norms about space, relationship and creative expression: each day one or two art counsellors would enter the camp and walk from tent to tent to gather those that wanted to join a group. the children would emerge, sometimes in hundreds following the blue trunk of art materials to the United nations high Commission for refugees (UnhCr) tent. Different configurations of groups would form – educators, women, men, adolescents and children of all ages. At times their therapeutic encounter would occur in the physical space of a tent . . . and at times out on the grass or under a tree. (Nhlapo, quoted in Berman, 2010: 14) here the therapists rise to the challenge of context, responding to resources, level of need and potential to create access and opportunity. this capacity to respond to particular context reveals the dexterity and responsiveness of the therapists and participants to their lived situation and the diversity of the arts therapies’ relationships to arts process. the following examples explore this responsiveness to different contexts and diversity in relation to arts process, access, space and relationship.

Case examples here are two contrasting examples of the ways arts therapists and clients create a space for the arts to take place in a therapeutic context:

Creating a space: music therapy haack and silverman’s (2016) music therapy aims to help alleviate negative symptoms and psychological strains associated with medical procedures. they contextualise their work by noting that some patients, recovering from an organ transplant may feel ‘unwell, anxious, and fatigued’ and that, rather than ‘an active intervention’ involving participating in music making, they ‘often desire a more receptive music therapy experience’. the research concerned ‘patient preferred live music’ (pplm) for individuals post-surgery in an organ transplant unit in the United states. this was a ‘single-session music therapy intervention’ where clients were visited once. the work was part of a preparation for a randomised control trial and, as a result, patients were divided into groups receiving three different interventions. one intervention involved pplm offered as a ‘simple guitar accompaniment’, another was a ‘complex guitar accompaniment’ and

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this was offered to all patients on the unit once per week. the third was a ‘control group’ who did not receive music therapy. the music therapist enters a patient’s room, enquiring if the patient is interested in receiving music therapy. if they answer ‘yes’, the therapist obtains consent and asks them to complete a simple pre-test form. the form asks them to rate themselves on the ‘Quick mood scale’ (Woodruffe-peacock et al., 1998) with items asking for self-description using terms such as relaxed or anxious, cheerful or depressed, clearheaded or confused. Additionally, patients were asked about their experience of pain in a single item structure used by the hospital – a 10-point likert scale, with 1 being the lowest and 10 being the highest. this is followed by an invitation to choose from a ‘song menu’ consisting of forty songs compiled by previous patients and those who had provided music therapy on the unit. these included songs from Bob Dylan, Bob marley, mumford and sons and rodgers and hammerstein: ‘Blowin’ in the Wind’, ‘three little Birds’, ‘the Cave’ and ‘edelweiss’. if the music therapist is offering a ‘simple’ guitar accompaniment they use chord changes, ‘simple strumming’, ‘root position chords’ and voice and guitar maintaining a ‘steady medium dynamic’ (2016: 35). the complex accompaniment offers a ‘richer chord palette’, suspended chords, complex strumming, percussive techniques such as plucking, fingerpicking with voice and guitar ‘adjusting volume and intensity depending on the song and section of song’ (2016: 35). haack and silverman note that patients would often sing along during the simple accompaniment, but not during the complex variation. their reflections are that patients are less likely to sing with the music therapist when they see the music more as a performance, as in the complex accompaniment. following the music, the patient completed the ‘Quick mood scale’ and the likert scale concerning their pain, once more, and the therapist leaves the room. haack and silverman note that clients report back to them that the single session created significant shifts in their mood: from being anxious to relaxed, and from feeling depressed to being cheerful. they conclude that music therapy created very simply and as a one-off event has a therapeutic impact: the single meeting with the therapist as they come into the patient’s room, engage in choosing a song, listening and in some cases joining in. Analysis of the data from the simple and complex intervention, compared to the control group patients who had neither, showed that this simple introduction and meeting ‘can positively impact mood in solid organ transplant patients’ (2016: 214). they explain the patients’ experiences by making the following connections: music therapists . . . need to be strong functional musicians and be able to play simple accompaniments



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in an aesthetically pleasing and competent manner and convey the essential elements of the song (i.e., the mood, feel, and supporting the lyrical content). perhaps this can be explained neurologically, as both simple and complex accompaniments may be effective as music has a clearer signal with less noise and promotes neuroplasticity (stegemöller, 2014). Creating a space: art therapy An art therapist describes how a young child client, John, arrives for the frst time in an art therapy session (Case and Dalley, 2014: 134–5). he comes in and, without taking his coat off, looks over to a box with toys in, moves over and takes out cars, commenting to the art therapist about the toys. the therapist notes his play, the way he moves the cars, keeps hold of some, and pushes others away. As he plays he asks about painting. the therapist asks if he wants to do some; he replies that he’s not sure. he then takes up the therapist’s umbrella, putting it over his own and the therapist’s head, leaves it on the floor, comes over to a table and asks ‘shall we do some painting?’ the therapist sees the playing with objects as a testing of the space and herself, before John feels safe enough to begin work with art materials. she interprets it as his seeing if the act of painting could be contained. he puts on protective clothing and then pushes paint out of tubes onto a palette. the therapist physically helps him when he has difficulty squeezing paint out, and the client paints a circle on a piece of paper. he dips his paint in white, then black and paints the circle saying ‘it’s all black’. he tries the same process again, and says ‘oh no, that’s all wrong’ and that he will have to throw it away. the client folds the paper carefully, and asks the therapist where the bin is. he goes on to make a cracker out of folded paper and asks the therapist to pull it with him. the therapist, in her reflection, sees a possible meaning in this: the client trying to mix together two different aspects of his life without success. the mess made him worried and anxious, which perhaps mirrored his inner experience. this is not reflected back to the client, however; rather it is the therapist attempting to note her own responses and ideas: the most important issue is that the picture surface has a “voice” of its own and gradually a dialogue builds up through which both patient and therapist communicate. (Case and Dalley, 2014: 134–5)

136 Agents of transformation   in the first example, the therapist moves into the patient’s room, provides presence, the offering of consent, a predetermined form concerning their current feelings along with a choice to be made from a predetermined set of songs. they then actively make music, by playing a guitar, whilst the patient listens and, perhaps, joins in. their explanation for the efficacy of the music therapy combines aesthetics, skill and neurological functioning. these include the music therapist’s ‘aesthetically pleasing and competent manner’ and sharing of a song, with the therapist identifying aesthetic elements that offer therapeutic effect (mood, feel and lyrical content), along with phenomena such as ‘signalling’ and ‘neuroplasticity’ (haack and silverman, 2016: 135). in the second example, the therapist does not direct the client into activity – rather she observes, providing physical assistance if the client requests. she notes her own responses and possible interpretations of what is occurring for John. the notion is that the client is initiating a series of relationships, testing the space as an arena for exploration and creativity, and seeing how they can relate to the therapist. the assumption by the therapist is that the room the materials used, the things made and the relationship between client and therapist all provide an ‘open space’. the client’s activities and responses are all held as potentially meaningful, and as involving an opportunity for expressing personal material. the therapist also attempts to find meaning through her own responses, feelings, observations and ideas. in haack and silverman’s way of working a structure is used to introduce the client to the art form. this involves a combination of fixed forms – the use of the private space within the room, the request to select material such as a song and a proforma to express experiences before and after the single therapy session. here they are offering an opportunity for the client to explore the art form as audience and as participant, in a single encounter, bound by consent, with a music therapist. in each case the client forms a relationship to creative expression. their first explorations are seen to hold significance. for Case and Dalley the therapist does not verbally provide meaning by telling the client what significances are potentially expressed within the work. Whereas the music therapist offers a structure to frame the song experience by the provision of the predetermined ‘Quick mood scale’. in both, though, the art form, the relationship formed within the arts process and the experience and feelings which the client finds are seen as significant, and provide opportunities for meaning to emerge within the potential space of the arts therapy. one of the fears for clients can be that the arts expression might be harmful rather than helpful: the improvisation and spontaneity being experienced as a lack of control or holding. here two clients talk about this:

Client account gloriA:

some of the role play had an adverse effect rather than clarifying. instead of coming out feeling i’d resolved something i came out feeling halfway through an issue – perhaps it was more deeply



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embedded: it took a number of sessions to dismiss, something had resurfaced . . . some issues are still deeply embedded. Jenny: i can’t put myself back together and everything feels foating and in bits and that stayed like that for a while so i felt on my guard . . . i don’t know how to handle it when i come home. he was good at getting it out but no good at telling me how to put it back. perhaps fnish a bit sooner and talk about what we’d done, and leave a bit more time at the end to stick myself together, pick up the pieces. (Casson, 2001: 24–5)

the fears expressed here are clearly sometimes experienced by clients, and echo some concerns about the nature of the arts expressions in the arts therapies being uncontrolled or uncontrollable. in part, such comments may be expressions of anxiety concerning the expression and containment of complex, held-in feelings or issues. however, they also emphasise the importance of appropriate containment within the arts therapies space. the extracts also reveal the importance of client feedback on their experiences. the dramatherapist, Casson, responds to these comments by ensuring a section of time for ‘re-integration’, de-roling, closure and preparing to leave the arts therapy space (Casson, 2001: 24–5).

Focus on Research: dialogue with new arts languages and cultures Interview with Nancy C. Choe This interview is based on the research ‘An Exploration of the Qualities and Features of Art Apps for Art Therapy’ (Choe, 2014). the focus on research material has a simple 2–3 line introduction – in each case i think there needs to be an empty line after it and the text in italics – i have gone through the book indicating this – so here from ‘this interview’ to ‘2014)’. the role of emergent arts forms and practices are a key aspect of how the field develops and research explores the role innovation can play in work with clients. Crooke (2018) has explored music therapy’s relationships to evolving ‘beat making practices’ in contemporary cultures in different parts of the world: hip-hop being given as one example Crooke argues that such dialogue with new forms is important for a variety of reasons: from understanding new therapeutic possibilities of the arts to avoiding the danger of ignoring or devaluing ‘the musical identity and preferences of certain clients or client groups’ (2018: 11). the following interview with nancy C. Choe addresses another dimension of emergent art practices: that of digital art. Choe challenges the ‘tradition’ of media in art

138 Agents of transformation   therapy: asserting that art therapy has mostly limited its practice, theory and pedagogy to drawing, collage, painting, photography and clay sculpture (2014: 145). her research examined the potentials and problems of using digital art media in art therapy. she explored art therapists’ perceptions and uses of the features and qualities of digital art materials, specifically art apps on ipads, for art therapy use. the conclusions were that there were distinct qualities and features considered as useful in relation to art apps and their potentials in art therapy. Jones: Choe:

What made you interested in art therapy and apps? i think my many years of working in digital design and marketing helped me have a greater appreciation of digital arts and its potential to be utilised in a therapeutic setting. the very frst time i used an app was in a hospital setting with an elderly client who was diagnosed with schizophrenia. he had a deep connection to his mexican culture, especially the culture of his childhood hometown. i felt a cultural barrier in establishing a therapeutic relationship with the client, so one day i brought an ipad into our session and went on google earth in search of his hometown. As i zoomed in and travelled through the streets and small alleyways, he thought i was performing magic! he quickly took control over the app to show me all the places that were personally meaningful to him. We shared laughs and awe as we journeyed through the streets of his hometown that, surprisingly, hasn’t changed much since his emigration. this frst clinical experience of using an ipad with a client inspired me to think about ways to use digital media in art therapy. Jones: how would you see your research in digital art/art apps in relation to the more traditional forms of art within the art therapy? Choe: Digital art is just as highly diverse and varying as traditional forms of art in terms of characteristic, quality and therapeutic use. Digital art can range from a simple simulation of painting or drawing to animation, digital storytelling, augmented reality, sound mixing, 3D-printing, virtual reality and much more. i don’t see digital technology changing the nature and effects of art therapy, as the basic premise of using the art and then having a refective process will always be there. however, i see it as expanding art therapy’s notions of art and therapy. Digital media provides a different way of engaging with the art material, art process and art product compared to traditional forms of art, and this requires an art therapist’s awareness, knowledge, and skills of digital materiality and technology in the context of art therapy. therefore, i think it’s essential for an art therapist to have ongoing engagement with developing digital competency before using digital arts with their clients. Jones: refecting back on the therapists’ refections on the way clients might use art apps, what strikes you as most interesting? Choe: i think art therapists are naturally creative thinkers with great empathy. i was struck by how easily the art therapists in my study (even those who had no prior experience with digital art apps or stated a personal



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dislike of digital art) spotted potential clinical applications in their work and thoughtfully critiqued the art apps as a client-user. Without even knowing, they were doing the exact same thing a highly skilled user experience (UX) designer would do in the tech world, which is basically designing meaningful and personally relevant experiences in a product. the way the therapists engaged with the art apps in my study eventually inspired me to go on a journey, or more like an odyssey, of trying to develop an art app specifc to the use of art therapy. in my journey, i found many similarities between being an art therapist and a UX designer. Jones: What are the main implications for future research and art therapy practice, leading from your enquiry? Choe: this is a very exciting time to explore what digital technology has to offer art therapy, because we are in the moment of massive digital infuence affecting all areas of our culture. my research was limited to the usage of digital art apps on an ipad, but there is a broad range of artistic practices in the digital realm that haven’t been explored by art therapy. With increasing permeability between the digital and the physical world, i see great value in researching how digital art materiality and digital visual culture can impact the therapeutic process. Developing research to articulate on the clinical and theoretical perspectives on digital media can also deepen our understanding of the many challenges, limitations and benefts of working with a medium that is constantly evolving.

Forms for feeling: improvisation and culture As we saw earlier in this chapter, the value of improvisation or the spontaneous has been a theme in many art forms in many cultures for many years. however, it is important to note that the particular values attached to improvisatory form at the heart of much use of the arts in the arts therapies are only one way of making. Within different cultures, eras or groups, other approaches to the arts are seen to be valid. Amongst these is the idea that the arts are solely or primarily the territory of trained artists. Artists are seen as people who have formal training, who may have access to specific, specialised techniques. they may be reflected in having a professional or ritual title, or their work may be given recognition through formal display or through payment. Another notion, often linked to the role of artist, is that of ‘talent’: some may view participation in the arts as being of value only to those who are seen as specially talented or gifted. some ways of defining art may have very specific requirements that an art form needs to have before it is recognised as valid. for example, someone might feel that acting needs a level of skill and expertise in depicting a character in a sustained and convincing way or that an artistic expression must have spiritual inspiration to be valid. others may consider that work with clay might need to have particular qualities

140 Agents of transformation   such as the creation of pottery with evenness of texture and proportion, or a musical instrument will need to be mastered in order to comply with ideas of the production of harmony, melody or rhythm. this may also manifest itself in issues to do with cultural difference. people’s expectations of the arts are linked to their cultural identity or background. factors in this might concern age – the expectations of different generations on art or music, for example; of culture – the different traditions in expression; or of religion – certain forms may be acceptable or not acceptable according to religious belief. All of these socio-political factors will have an impact on the client and therapist’s encounters in arts therapy practice. Within a group there may be different views on spontaneous expression compared to rehearsed products or crafted form, for example, or there may be different expectations or associations regarding what form of expressions an art form can take. these feelings may affect the way someone participates. if, for example, their expectation is that an art form can only be produced through training, this might restrict their capacity to engage with the arts therapies’ cultural norm of ‘spontaneous’ arts work, where the emphasis is more on the arts as a reflection of personal material than on highly crafted and finished work. some clients may feel frustrated because their capacity to maintain character or express themselves through an instrument are frustrated by their unfamiliarity with the modes of expression possible within the art form. Arts therapists might work with the feelings this arouses, but also might assist the client in deepening their participation with the art form’s modes through their exploration and usage of media or processes. others would see such differences between people’s cultural ideas about the arts, and their different levels of experience, as part of the potential within the therapeutic encounter. these are openings to learn about differences, and to see such areas as reflecting other issues to do with diversity and difference in their lives and experience. the arts form and process within the arts therapy becomes a place to explore differences and similarities between clients, between therapist and client, and the client’s own opinions, thoughts and experiences about their relationship to their own culture and to others’ cultures. movement psychotherapist Callaghan sees the arts therapies as having particular value in this area. such differences are to be shared, and are a potential for mutual adaptation. she gives, as an example, different attitudes to space and touch, adding that ‘the arts are inherently radical and encourage creative exploration. these factors help individual movement psychotherapists to resolve conflicts between traditional models and . . . new approaches’ (Callaghan, 1996: 262). the arts therapy space can become one that reflects and encounters the artistic approaches of all its participants. this reflection, though, occurs within a framework that is rooted in the assumption that the art processes and work are ‘radical’, to use Callaghan’s word, and will be centred on exploration and improvisation. so, any cultural form used will need to be open to dialogue with the idea that it can act as a vehicle for personal change. As we have seen, expression in the arts therapies is based in



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improvisation. however, in working with clients from backgrounds or with experiences which do not reflect these norms, arts therapists traditionally set up dialogue by creating opportunities for the client to work within expressive forms which reflect their cultural identity. it is normal, though, for these to be adapted within the arts therapy session. music therapist Amir, for example, positions her work within the need to look at clients from a cultural contextual perspective instead of one that ‘focuses only on the individual as a totally independent entity’ (2001: 1) she describes her work from the perspective of her own and her clients’ cultural experiences of traditional song: ‘in my music therapy practice in israel, singing israeli folksongs often serves as a very important and dominant element. Very often the song repertoire chosen in my music therapy groups represented personal, usually unresolved issues concerning interpersonal relationships, death, bereavement, grief, ageing, past history, present and future’ (Amir, 1998: 217). A client, rina, brings a traditional folk song, ‘rakefet’ or Cyclamen, to the music therapy group. this was a song she sang to her deceased daughter: ‘i asked rina to recite the song as if it were a poem, while the group hummed the melody and swayed together. i also asked her to close her eyes, imagine her daughter as she recited the song, and dedicate the song to her daughter.’ this becomes a part of a process of exploring rina’s depression, sleeplessness and grief. the therapist describes it in this way: ‘rina, together with the group, mourned her daughter. While reciting the song she had a very powerful insight: the cyclamen became her daughter.’ this is seen to mark the beginning of rina’s being able to ‘start the mourning process and to begin to separate from her daughter’ (Amir, 1998: 227). As we shall see, dance movement therapists work with dance forms their clients bring, but then introduce an improvisatory or exploratory element. Arts therapists work with cultural references and ways of making rooted in the client’s previous experience. however, these are used within a framework of change, and where the images made are seen as personal material. A dramatherapist, for example, might use a script or text from a client’s own cultural background, but might develop this with the client for improvisation and personal exploration.

The art form and the triangle in some arts therapies the materials or expressive media are easily seen to be available, and so, in many contexts, the client’s initial response to them does not need a signifcant amount of direction or advice from the arts therapist: for example in the art therapy open studio, where materials are in an allocated room, or forms of music therapy where a variety of instruments are present in a room. here the emphasis can be on the client responding to the opportunities, stimuli or challenge of three things: the materials or expressive forms; the creative and therapeutic opportunity presented by the space; and by the potential relationship with the therapist.

142 Agents of transformation   the stress is on the client’s responses to these three areas. As we’ve seen, the client’s response to the arts opportunity for expression and the developing relationship with the therapist reflects the concerns or issues they are bringing to the arts therapy. the relationships between the three are seen as opportunities to begin to use the therapy. therapists often understand the way the client uses these opportunities as having various degrees of conscious awareness. By this i mean that in some situations clients may be very aware of what troubles them, or why they have come to therapy, and deliberately try to use the arts materials, space and relationship to communicate and explore these areas. in others, the clients may not have such conscious awareness, and express them unconsciously through their responses and participation. lawes, for example, had been in individual ongoing music therapy. he talks about his experience as a client, exploring unresolved issues concerning his mother’s death from a brain tumour many years earlier. he describes the original situation in his life as offering no real understanding, or holding, of the impact on him and his family of her illness and death. An image forms in his mind and this is shared with his music therapist: of ‘a boy sitting silently in extreme cold, darkness and desolation’ (lawes, 2001: 24). he talks about how his signs of depression and rage resulted in his being told that he was ‘difficult’. he describes how he began to experience the music therapy as an opportunity ‘to try to find some music to articulate and hold this experience together’ (lawes, 2001: 24). he says that he feels his therapy had been heading towards a particular point for three years ‘and now it was time to see whether the boy could find any music to articulate this scene beyond words’ (lawes, 2001: 24).

Client account At the piano, i knew that i had to become this boy fully and let his hands play the notes. the frst letting-go was the most disturbing and frightening experience in music that i have ever had. i found myself playing incoherent discords with no sense of meaning or energy; it felt as if i were dying and completely disintegrating. then something began to happen as the boy started to play the music which articulated what he was seeing. i suddenly knew that he was only a few months old, which is why he could not speak. in my imagination i was able to see my dead mother and respond to her. i felt that i was able to remain human, to experience and articulate my tender and compassionate feelings. this profound experience in music gave me evidence that i could not doubt . . . it was my frst completely improvised music, and was an experience of ‘therapy in music’ in the most healing and transformational sense for me.



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the music itself had a kind of repeating heartbeat motif involving two notes of a minor chord with a wide spaced two-part chorale above . . . Around the sounds, the music articulated sheer silence. there were several versions over two or three days, and then i seemed to have done enough. An image came to mind of a deep-sea pipe on the ocean floor that had come apart years before, but had finally been rejoined by this boy who could not speak. Being able to look at my dead mother meant finally being able to separate from her. (lawes, 2001: 24–5)

lawes is familiar with music and musical form, and this affects the way he is able to articulate his experience as a client. the process of the music therapy has enabled him to gain insight into the direction and focus of the work. he has decided on the area he wishes to explore, and goes into the music with an intention to look at issues concerning his dead mother. Beyond this, though, the form that the music making takes is unplanned. the experience is framed by the client as one that allowed him not to plan or compose, but to allow spontaneous improvisation to occur. this is seen as a ‘letting-go’ in relation to the letting-go he had to endure as a boy on the death of his mother. this allows feelings, images and musical form to combine in retrieving or evoking an experience, and in working through his contemporary distress that was held in the image of the silent boy. As described in Chapter 4, the experience of the client here uses the qualities of music to evoke hidden memories, to express and contain material that cannot be put into words, and to revive experiences in the present of the therapy session. he decided on the area that would be the focus of his therapy, but the form and process lie in the spontaneous use of music within the therapeutic relationship. this evocation into the present of the therapy session through musical form enables unresolved, silenced material to be expressed and communicated. the importance of the therapist is described by the client as ‘she sat with the boy who could not speak’ (lawes, 2001: 26), and provided the space and opportunity to work with the material. lawes says that insight or understanding alone would not have been adequate for him. he stresses the importance of the ‘aesthetic/ emotional nature of the music’ in allowing him to have an experience that was encountered through the senses, and was highly emotional. his feeling was that the music and emotion came together from his unconscious during the spontaneous improvisation, and that this was a crucial factor in his work in the therapy. for other clients, though, the importance lies in the ways in which the triangle of client, art form/process and therapist is used to express material which they either cannot use words to talk about, or of which they are not consciously aware. someone might not be able to focus with lawes’s precision on what troubles them. some argue that expression through the

144 Agents of transformation   art form itself, in the presence of the arts therapist, provides a container in ways that parallel Wood’s comments about the studio earlier in this chapter. silverman (2007), for example, talks about ‘trusting’ the art form and metaphors created by the client, seeing a delicate and fine balance in not pushing for any verbal articulation or interpretation of meaning. in her work with an adolescent who has suffered early sexual abuse, silverman talks about a journey to naming and sharing the abuse. for a substantial part of the therapy the client expressed herself with images, stories, as the relationship to the therapist, arts process and therapeutic space developed. the client had chosen a story to explore – a traditional story of the daughter of a miller whose hands are chopped off. she leaves her family, living in a forest, surviving without her hands and, over time, they grow back. the client creates the images of hands in drawing and improvisation and works with them weekly over a period of months. silverman talks about this in a way that connects with lawes’s experiences: my approach was to trust the metaphor, to trust that the image of the hands in the fairytale had touched her deeply. i knew that she was still extremely fragile and that one wrong move on my part would send her away. i never asked for self-reflection or answers and i never interpreted what she did. We stayed in the metaphor, in the character of the hands and within that structure she thrived. she discovered a universe within a narrowly confined theme. (Silverman, 2007: 257) After six months of parallel work with these images, the client responds to the prop of a rope in a session and, accompanied by a physical response of shaking and ‘being frozen’, a repressed memory of abuse by her father returns to her and can be expressed directly: she sits with the therapist and ‘when she could speak she told me her story’ (2007: 257). silverman’s analysis is that this first direct disclosure of the client’s real-life experience is made possible through the relationship between therapist, client and arts processes over time as trust is built and the adolescent girl can approach material at her own pace. silverman describes their work as allowing expression and participation in the therapy: ‘access to the adolescent’s own subjective narrative, something not easily accomplished with conventional therapies’ (2007: 254). the arts therapy provides the client with a ‘sense of control’ through the art form, of ‘symbolic material’, which allows the prevention of ‘emotional flooding or re-traumatisation’ (2007: 253). in both this case and in lawes’s therapy, the arts processes and therapeutic relationship allow material to emerge in ways that words alone would not permit, and for change to occur. some clients, for example those with severe learning disabilities, may not use verbal language at all to communicate. here the triangle provides a way into the beginning of non-verbal expression and exploration. the arts forms and processes are seen as a rich language, which allows material to be discovered or for issues to emerge in ways that need



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to be oblique. one way of understanding the creation of images, patterns, relationships within, and through, the art form is that they can allow ‘censored’ material to emerge. they can also create a sense of safety for the client to play, or allow a distancing which gives the client permission to express material which they would not be able to name directly. the following are client accounts of aspects of this process. the first is from a project working with young people aged 16–25 in Australia:

Client comment ‘What a lot of people get out of art work is, like, if something is disturbing them like, let’s just say they got assaulted once and it was traumatising for them, and they don’t want to tell anyone about it cause it is their secret. they put it into artwork it helps them get it out’ (yp015). ‘[i] saw it more as, like a, i suppose mindfulness exercise. i like thinking, so thinking and introspection is always a big theme for me, so that’s why i enjoyed it’ (yp011). (gwinner, 2016: 13)

here is a description of a similar process of discovery from the point of view of a UK client working with integrative arts psychotherapist, James.

Client comment ‘i arrived at my session with a familiar feeling of wanting to talk but not feeling able to articulate my words. i felt full of feeling, confused, churned up. fortunately for me i was surrounded by a choice of expressive media. i chose paints. this i could do in silence. As i painted tears began to fow and i felt more confused, more anxious and yet purposeful even though i had no idea what i was painting or how it would turn out.’ she describes staring down at her painting, and feeling irritated that she could not ‘make sense’ of it. James encourages her to stay with the image. together they look at it from ‘as many different angles as possible’. eventually the client says she is surprised. ‘An image of what looked to me like a detached breast with its nipple pointing towards a foetus emerged. i was adamant that the baby must not drink from the breast. it was bad, a false breast. i cut it out of the picture, having found my voice at last.’ (James, 1998: 20–1)

the idea here is that the client finds his or her own way into the material and that this lack of conscious intention in relation to the art form allows

146 Agents of transformation   such opportunities to be maximised. Whilst the art form is crucial to this, the concept of the ‘triangular relationship’ always needs to be kept in mind to try to fully see the meaning and effect of the work. this refers to a core process in the arts therapies: the potentials of the relationship between client, arts form or process and the therapist (see Chapter 17).

Meaning, effect and the triangular relationship • • • • •

Does the way the client responds to the materials and expressive possibilities say something to the therapist? Does the way the client responds to the materials and expressive possibilities say something about the way they feel about the space? Do they reflect some of the issues the client brings to therapy? Or, put another way, is either of these areas being used as a way for the client to begin to bring their concerns to the therapy? Do the feelings evoked in the therapist by the client’s use of the therapy and their response to the art form provide any insight into what the client is bringing to the therapy? How do parallels and differences between the cultural backgrounds and experiences of the client and therapist feature in meaning making: both of the expressions made within the arts therapy and the relationship between client and therapist?

these questions are often present within the therapy concerning the making or expression of arts work. they might inform the way the experience is understood or talked about. the temptation is often to look at the image, dance movement pattern, role-play in terms of its content primarily – and to use this as the main focus of seeing what is happening in the therapy. however, by bearing in mind the idea of a triangle that relates to client, the art form or process and therapist in the arts therapy, a fuller picture can be seen to emerge. these areas will be considered in more depth in Chapters 14, 15 and 17 concerning the client–therapist relationship.

Experience of the client and meaning A number of practitioners and theorists have referred to the notion that the arts are a way of ‘making meaning’ – of discovering and communicating. As the therapy space and the relationships are engaged in, as the client begins their work, the area of how the arts enable meaning to emerge in particular ways for the client is often seen as central to arts therapy practice. Warner talks of a constant human drive to make visible the invisible. she traces this through art making, ‘the desire to make unperceived objects



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of fear and fantasy stand before one’s eyes as if they were real’ (Warner, 1996: 11). she illustrates this from history. for example, after the creation of the magic lantern one of its first uses was to project onto a wall the image of a soul burning in purgatory. the ‘most exciting optical instrument’ of the day was ‘immediately used to make visible something that of its very nature cannot be seen and does not exist in visible form’ (Warner, 1996: 12). Warner focuses on the human capacity to conjure up pictures in our heads. Whilst we are standing in a market queue, for example, pictures can form in the mind of memories, fantasies, hopes or daydreams; some seen by the eyes of the body, and some not. she concludes, ‘Consciousness is a picture palace, among other things; and one that is filled with phantasms’ (Warner, 1996: 12). how do such images have meaning for their creators? the artistic creations within arts therapy sessions can, similarly, be seen as a kind of ‘picture palace’ of the clients’ making. the ways in which meaning emerges from the image making, music making, enactment or movement are seen as an important aspect of the clients’ experience of the therapy. music therapist Aldridge talks about the way in which the artistic product, or the process of making, acquires meaning in terms of empiricism: knowledge being gained through experience. this is seen as the heart of what the arts therapies offer the client in terms of their experience of themselves and their lives. Aldridge uses this way of considering meaning to say that knowledge comes through the senses and that this is linked to ‘cognitive perception’: this cognitive perception is a process of organization where meaning is imposed upon what is heard. in this way a seemingly meaningless ground of sound is given meaning. to perceive, then, is to give meaning to what is heard, an act of identity. however, the non-sensory process of cognition is transparent, or rather, silent, and appears as if hearing were solely a sensory experience. (Aldridge, 1996: 25) Within the arts therapies it’s possible to say that there is a useful tension between arts making and discussion, reflection or analysis. some such as skaife have described this tension as a potential for ‘radical therapeutic possibilities’ (2000: 115). the question raised by some therapists is whether the experience itself is enough: whether the artistic and therapeutic experience in the art form needs to be verbalised as reflection in order for meaning to emerge. As music therapist pavlicevic puts it: When working with verbal clients, is it through verbalising the musical, non-verbal act that both the therapist and client give the experience meaning – and possibly prevent

148 Agents of transformation   it from slipping away or disappearing? Were we to leave the musical experience to speak for itself would it remain unconscious, un-recovered, unaccessed by the client? (Pavlicevic, 1997: 10) Do words detract from the experience? or do they invite a coherency and a certain kind of cognition upon experiences that do not happily ft into verbal language? nordoff and robbins have said of music therapy that ‘the therapists make no effort to establish a relationship with the child other than on the basis of musical expression and musical activity’ (nordoff and robbins, 1977: 189). in contrast to this, John says that: music is half the management process: conscious assimilation needs words in order that the unconscious material can be managed and thought about. this process of music being literally a medium through which unconscious material can bypass repression and become conscious in words form[s] the basis of music psychotherapy. (John, 1992: 12) simpson, in his study of using words in music therapy, concludes that the use of verbal language within music therapy has a variety of different functions and purposes. these comments, i think, are relevant across the arts therapies. the purpose and use of words vary enormously depending on the client group or on the individual client – for some clients verbal language will not have meaning, for example. simpson’s analysis of the work of several therapists and their relationship to verbal language looked at the ways words could both facilitate and hinder the process. Words could hinder by being used to avoid engagement, to dilute the arts experience, or to remain cognitive as a defence against spontaneous or emotional engagement. Alternatively, words could help in putting clients at ease, creating opportunities for insight for both client and therapist, and to give feedback and enhance the experience (simpson, 2000: 87). he concludes that ‘music itself is the transforming locus of the therapy. Within the therapeutic frame, words can be considered as wrapping around the music as a secondary “skin” of interaction’ (simpson, 2000: 86). i’m not entirely happy with this image of words as a containing skin, though. his study indicates, as described above, the many roles verbal language can have within the arts therapies, but for me the relationship is one that involves a flow – and not a distinct difference as the image of a containing skin suggests. i don’t see words as necessarily so separate from the art form – one can move into another, images can contain words that need to be spoken, words can contain images that need to be enacted, sounds can move into words and vice versa. one of the therapists in simpson’s study acknowledged a part of this when they said: ‘the therapist can hear the tonal range, rhythmic characteristics and flow of



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the client’s words, and in this way begin to enter the music that underlies them’ (simpson, 2000: 88). the therapist needs to be able to respond to the client, and to be as sensitive as possible regarding when words seem a defence and an avoidance, or when they are an aid and an integral part of an arts therapy process. many arts therapists would find sympathy in the advice written by Jung to ‘mr o’. the quotation below is from one of a series of letters to mr o, who Jung is advising about the use of what he calls ‘the active imagination’. he’s talking about a dream that mr o has described: a quantity of yellow substance has grown under the hand of the dreamer. Attempts to wash it down the drain fail because the drain is blocked. Jung’s advice is to work with the image – to start with the yellow mass:

Jung and the yellow mass Contemplate it and carefully observe how the picture begins to unfold or to change. Don’t try to make it into something, just do nothing but observe what its spontaneous changes are. Any mental picture you contemplate in this way will sooner or later change through a spontaneous association that causes a slight alteration in the picture. you must carefully avoid impatient jumping from one subject to another. hold fast to the one image you have chosen and wait until it changes by itself. note all these changes and eventually step into the picture yourself, and if it is a speaking fgure at all then say what you have to say to that fgure and listen to what he or she has to say. (Jung, 1997: 164)

in a later letter (1997: 165) he talks about the importance of stepping into the picture with what he calls ordinary human reactions and emotions. he says that not only will mr o analyse his unconscious, but that he will give his unconscious a chance to analyse him – and thereby begin to create a unity of unconscious and conscious, and the route to ‘individuation’. interpretation, or the emergence of meaning through interaction, is often seen as something that can engender change. this occurs through insight and the mediation of artistic expressions made within the relationship between client, art form and therapist. A connection made with suppressed images, for example, can be seen to vitalise the client’s conscious life. the importance here is the idea that expressions through the arts, such as images or movements, can be ‘carriers’ and hold potentially useful meanings. in addition, arts expressions and forms can allow distance, or an added perspective. interpretation is one way to use the urge to make the ‘invisible visible’ that Warner talked of. Consciousness can mediate meaning from arts expressions made within the therapeutic relationship. the particular relations between the unconscious and interpretation in the arts therapies

150 Agents of transformation   will be looked at further in the next chapter. more generally, we can say that, looked at in this way, the arts become a way of making meaning – of discovering and communicating meaning in a dynamic process of change within the arts therapies. music therapist pavlicevic sums up issues around meaning in the arts therapies in a succinct and illuminating way. she says that ‘the act of embodying, or of making the thought “flesh”, be it through music, sculpture, art or words, prevents it from being suppressed, repressed, or disappearing altogether. however, the nature of this embodiment may give the thought a different emphasis, a different dynamism and a different colour’ (1997: 10).

Expressive forms of the arts so far we’ve looked at the way that the client and therapist begin to engage with the arts therapy language and process, the ways in which a client might enter into expression, or begin their use of the medium, and the way in which meaning can emerge. Do the different art forms in the arts therapies make any difference to the client within these processes? Does the choice of dance movement compared to music make any difference? Does this infuence the direction or effect of the therapy? i want to contrast some examples to look at this. As we saw in part ii, the different arts therapies mostly use specific areas of artistic expression and process. gale and matthews, in a collaborative project involving an art therapist, dramatherapist and music therapist, for example, noted areas that were parallel or similar. they also recorded areas of language, session structure, ways of relating to clients and the use of physical objects that were different (gale and matthews, 1998: 182–3). But what exactly are these parallels and differences, and do they make any difference to the client? i want to briefly look at the arts processes in the arts therapies as a way into exploring this area. i will look at all the arts therapies, but will focus on dramatherapy and music therapy in slightly more depth, as examples. in my experience of working with students and trained arts therapists within the different disciplines over the past thirty years, there are three responses arts therapists often make in relation to participating in each other’s arts in workshops. one is suspicion that the other art forms are anxiety-provoking, that it’s ‘not their language’, they feel de-skilled and unable to express themselves as they would do in their ‘own’ art form and they are reluctant to engage. the second is that in response to potential difference they say, ‘but we do that too’ or ‘that’s no different from when we . . .’. the third, and the one of which this book is, i hope, a part, is interest in the others’ forms and practices, as a way forward for mutual discovery about the arts and change in therapy. in the way they have evolved to date, the individual arts therapies have both things in common and elements of difference. the next section looks at the way in which some aspects of the arts forms emphasise, or



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foreground, some processes, experiences and kinds of language over others in the client’s participation. Dramatherapists, for example, use all aspects of the spectrum of dramatic expression. this varies from early movement relationships through to staged enactments where roles are played in front of an audience. the main ways of working include role and improvisation; work with objects, story and movement. more specifically, role-play and improvisation might be used to explore material brought by the client. in some contexts this might be a deliberate re-creation of a life situation. other situations might be more oblique: for example, creating an improvisation with imaginary characters in a fantasy situation. in a role-play based on a life situation the client might cast members of a group, or the group and therapist, to play people from their lives outside the therapy. the client might play himself or herself – so a difficult encounter might be played out in the group. the idea is that this piece of life is brought into the session, and can then be looked at afresh by the client with the support of group members. emotions can be re-experienced, but can be worked with, reflected on in the space of the therapy. movement or physical theatre is seen to develop the client’s ability to express themselves bodily. here the emphasis is more on non-verbal expression than in role-play-based activity. Words might hinder some clients, so the experience of working non-verbally might permit expression and exploration. Words, for example, might encourage censorship or defensiveness. Work that focuses on the body might allow material expression through a change of emphasis or a different kind of permission that can be given when verbal language is not the main means of communication. Clients may play themselves directly, or may take on other characters or identities. this might mean playing people from their own, or other group members’ lives, or they might play fantasy characters. this work might include masks, costume and scenery. the dramatherapist can stay outside the activity, acting as a facilitator for the process as a whole, or making suggestions as to the way the work might develop, suggesting techniques, or asking questions as the work develops. some dramatherapists might take on roles during the work, playing a part within the action. Drama in dramatherapy, then, emphasises physical work – the client often uses their body either through improvisation or role, movement or physical play. Dramatherapy foregrounds the therapeutic potentials of identity transformation through taking on the roles of others, fantasy characters or gives opportunities for the client to play themselves in a different time or space. in group dramatherapy a client also engages with others who have transformed their identities – for example, in a role-play where a number of people have taken on roles. the client can leave their usual identity with its attendant ways of behaving, and try out new ways to relate, or respond, to people or events. Dramatherapy foregrounds the client’s opportunity to ‘try not being themselves’. in addition, other people may depict the client. others in the dramatherapy group, or in some situations the therapist, may

152 Agents of transformation   play the client – the client can look at him- or herself. this might occur through someone playing them, through role-play, or video playback. this foregrounds the reflective capacity of the client being outside their normal self and looking at their own life. this reflexivity and transformation is different from art therapy and music therapy, where the therapy does not emphasise pretending bodily to become someone else, or playing a role, or the client’s seeing someone else playing themselves, for example. Dramatherapy backgrounds areas of experience such as the idea of physiological change due to sound, or the use of objects made through painting, or use of clay to express feelings and the relationship with the therapist. it backgrounds the use of instruments to create improvisation and communication between therapist and client, or between clients, and the use of the client listening to recorded music as a primary agent of therapeutic change. in music therapy, the experience of music might vary from direct involvement in improvisation to the client and therapist listening to recorded music. A client might listen to music produced by the therapist, or work might consist of the client lying on a bed which makes use of the vibrations caused by musical sound. the nordoff robbins (1977) approach, for example, involves the client in making music. the therapist can make music with the client, encouraging them to improvise with musical instruments. practitioners such as Darnley-smith (1996) have pointed to the importance of twentieth-century music developments in relation to music therapy’s use of the art form in such situations. she points out a wide range of harmonic and tonal sounds which neither provide a formal resolution nor have a sense of recognisable form. she says this has contributed to the musical space in music therapy, which can allow sounds not crafted into compositions, and which she characterises as ‘raw’ and ‘spontaneous’ (Darnley-smith, 1996: 2). in some work the therapist participates in the creation of music. the therapist may sing with the patient, or play with them on an instrument such as the piano. this approach does not necessarily involve interpretation in the psychoanalytic sense. the creativity of improvising music, the relationship developing between therapist and client, are seen as the therapy. in this way of working the therapist tries to match the mood or feel of the client’s music. Bunt describes how, working in this way with children: behaviour can . . . be answered by the therapist in a way that partially imitates but also extends that communication, so as to indicate an understanding of what the child was attempting to express. for example, a child may play a drum at a quick tempo which is taken by the therapist to indicate a feeling of excitement: the therapist then plays the drum (or responds via another modality such as the voice) at a similar tempo but also loudly. turn taking between the child and therapist may then ensue. (Bunt, 1997: 255–6)



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rhythm is also used – this is seen as a communication. especially interesting to music therapy is the notion of personal rhythm. rhythm is seen as something which expresses the self, but which also can be important in communication between people. Circadian rhythms such as sleep and temperature or of breathing and pulse are considered in this way: ‘it is rhythm that provides the ground of being, and a rhythm of which being is generally unaware. rhythm is the matrix of identity’ (Aldridge, 1996: 29). Alvin writes that ‘Drums or percussive instruments can speak to one another and express unlimited kinds of feeling through rhythm, tone and intensity’ (1975: 16). Areas such as volume, tempo, phrasing, responsiveness, and the musical relationship are paid attention to. music foregrounds non-verbal communication through sound – the use of instruments or the use of the voice singing but not using words. this might help those for whom the cognitive use of words, the conscious awareness that words might bring, is not appropriate. they can find expression using sound: ‘music can sometimes effect communication with a completely withdrawn patient when other methods have failed’ (gruhn, 1960: 4). music foregrounds hearing. though other senses such as seeing are present, hearing is the sense most appealed to. people who do not or cannot use words or sight easily, or at all, might find expression or communication particularly effective through this mode. the use of instruments allows parallel playing or singing. the use of rhythm creates opportunities for feelings or relationships to be established in particular ways. the effect of music on physiological and psychological states has been looked at in terms of the effects of sound. here the emphasis is on the physiological effects or benefits for the client. music helping recall in coma patients is one example of this way of looking at change (Ansdell, 1995). rider (1987) has undertaken research on the effects of music on the body’s immune system and the reduction of pain and stress. Vibro-acoustic work, which focuses on areas such as the use of low-frequency pulsed tones through adapted beds, is also an aspect of this area of music therapy. music can also foreground cultural experiences of song, evoking memories and associations, group processes and engagement in singing. music can emphasise the ways in which objects can be used to form and hold relationships. in contrast to art therapy where the object is painted or made and in dramatherapy where the object may be reminiscent of toys, in music therapy the object produces sound. music does not involve the creation of objects through mark making or manipulation in the same way as art therapy. the focus is more on the use of objects to produce sound, or relationship, through making music, or being handled and passed, compared to the use of objects in relation to image making in art therapy. music backgrounds the creation of fictive states. much music therapy stays in the here and now of the playing, rather than moving explicitly into fantasy states involving taking on other identities. Aspects of the client’s identity might be foregrounded, or experimented with in creating sound, rhythm or lyrics, but they do not normally consciously play a character, or another client, for sustained periods of time. music backgrounds the use of

154 Agents of transformation   the body in the way dramatherapy or dance movement therapy might seek to express identities or the development of themes through playing roles and creating stories. Art therapy often foregrounds the creation of images and of objects which can be kept beyond the session in which they are created; the made thing is kept over a period of time. Art therapy emphasises engagement with materials such as paper or clay which are used to reflect personal material and to create images. the direct expressive potentials of the body of the client are not used as frequently as in dance movement therapy or dramatherapy, where the client could be engaged in physical movement, or mime, or expressing a role physically through the way they move their body. Art foregrounds the client’s staying within their identity. the focus is on what they have made; they do not normally enter into different identities through role-playing. When looked at within a model which focuses on transference, a part of this is that the client may take on different aspects of themselves within the interaction. they may, for example, feel like a child, a parent, a rival within the therapy, but within this they normally stay within their own identity. there is no formal shift into taking on an identity by role-playing and pretending to be themselves at age 7, or taking on the movement qualities of their mother in order to depict her. similarly, the therapist would not actively take on a role, as in dramatherapy, where the therapist might play a role in the client’s imaginary world, or in dance movement therapy where the therapist might touch or enter into physical engagement and movement work with the client. Art foregrounds the creation of a private creative space – there is often a period of time when the client engages in solitary creative activity – drawing or painting, for example. the therapist is present, others may be present – but the emphasis is upon private space and engagement. the exception to this is group painting, or work created in dialogue with a therapist. however, with these exceptions, art therapy creates opportunities for privacy in work in ways which are not often paralleled in the other arts therapies. there work is more usually actively witnessed by the therapist, or made in front of, or with, others – for example, the creation of sound and music, movement or enactment. one of the few areas that are parallel is the use of approaches related to world technique in play or dramatherapy, where a sand tray or objects may be used by clients to play privately. Wood describes ‘reverie’ as an aspect of these kinds of space: Art-making involves reverie and this can be totally absorbing . . . studios throughout the centuries have contributed to the environmental circumstances that make this possible . . . the life difficulties experienced by many clients are extreme yet the availability of a studio can add to their capacity to face what they feel. this is because the actual making of art can engender a sense of thoughtful absorption and this can make it possible to reflect upon what is felt and then



  The arts in the arts therapies 155 possibly even to see the feelings in the artwork. this is uniquely a part of what art therapy can provide. (Wood, 2000: 42–3)

Art emphasises the role of images as mediating between self and experience – the potential of a made, physical image to refect, transform and mediate. Dance movement therapy foregrounds the physical development of relationships through dance and movement as a cultural form that allows participation and connection to a person’s culture. movement prioritises the body as communicator, and foregrounds areas such as non-verbal communication and signals made by the body. it foregrounds the ways in which discomfort, distress or illness are reflected through the body and the ways in which movement can both reflect and release. the way the body and movement connect to identity is central to Dmt. Client experiences emphasise this relationship between the body and identity, and the way in which movement reflects and allows change in this. it involves ways of working that stress how the body can experience release, transformation and new ways of experiencing the self and relationships with others through movement. it also uses the potentials of dance and movement as ways of expressing, exploring and transforming relationships. Dance movement therapy uses the physiological effects of movement on the body. the notion of bodily development is drawn on, and the way in which an individual grows and develops through their body. there are stages in the way someone relates to their body, and to others through their body. Developmental stages can be worked with to assist development that has not occurred, or which has been blocked. these, then, are brief summaries to give a flavour of the ways in which the art forms can be seen to highlight certain processes or aspects of expression. obviously these are very general statements, and each client and therapist’s experiences will differ. however, i have attempted to provide some sense of the ways in which the arts therapies may differ for those involved. part V discusses these areas in more depth.

Does the art form matter? it’s possible to see in these brief outlines areas that are parallel and that are different in terms of the ways in which the client might experience the art form and process within the arts therapy. having reviewed the different modes and means of expressing, it’s important for us to ask: does the expressive form matter? Does it make any difference to the client? if there are differences, what are they? the creation of an image in art therapy through painting, compared to a story enacted in dramatherapy, is experientially very different. the expression and encounter with the arts medium of the client varies considerably if looked at in this way. i think it is possible to say that, within the variety of practices that have been developed, clear differences can be identified

156 Agents of transformation   between the languages and processes at work within the different disciplines. there is little extant art therapy work, for example, which consists of the client’s role as primarily audience to the art therapist’s painting or, in the case of the dramatherapist or dance movement therapist, the client’s experience as primarily witness to the acting or dance of a therapist. however, one approach within music therapy involves the therapist playing an instrument whilst clients witness – their role is to be involved by listening, not making directly. As an example, this primacy of witnessing the therapist illustrates the way in which the use of one arts language and process can create a difference in the client–therapist relationship. other contrasts do exist – for example, as described above, some dance movement therapists become directly and bodily involved in moving and touch with clients, however, whilst art therapists may engage in painting art work with their client but rarely engage in prolonged physical touch. here the difference between the art forms has an effect on the relationship. the engagement in touch, body work and movement is substantially different from mark making with the paper and instruments as an expression and embodiment of the process and relationship. these examples illustrate that there are some differences of method, tradition and experience for the client. so, can we say, for example, that the client’s experience in music therapy is substantially different from that of the client in art therapy? the answer is yes and no. the arts forms discussed have shown the ways in which the different arts processes and languages within the arts therapies have both commonalities and differences. the ways the art form affects the relationship between client and therapist also has commonalities and differences. We have seen that the arts therapies argue that they foreground the healing possibilities within the arts and within the potentials of relationship, expression, communication and reflection that the arts engender. for the client the different arts therapies do offer different languages and opportunities. i would argue, though, that the above descriptions illustrate that, even though the arts languages and processes within the arts therapies differ in some areas, it is possible to identify common processes which are at the core of change within the arts therapies. the above consideration of arts languages and processes has shown that there are differences, but i will argue that there are processes that can be identified across the arts therapies that create a common link. these will be described in Chapter 17.

Conclusion the arts therapies, then, utilise the potentials of the arts for healing. Within the diversity of languages and processes they foreground spontaneous or improvisational expression. on the one hand the engagement with arts processes and products can allow for a different experience for clients. patterns, way of behaving can be reproduced but in a way and in an arts therapy space where refection might be possible, where re-working the experience is possible, and where the client can attempt new ways – a re-learning.



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the arts processes and languages allow access to material or issues through images, dramatic process or music, for example, within the therapeutic relationship. these are different from the original experience, and yet can create or re-create aspects of the original experience. they are enriched containers or coded expressions. the difference is that the client can give themselves different permissions. they enter a playful relationship with the experience because they express it through artistic means. in addition it is created or re-created within the boundaries and opportunities of the therapeutic space and the therapeutic relationship. the arts therapies also draw on the potentials of arts forms as experiences involving creativity and different kinds of qualities or opportunities for expression and relationship. they might, for example, use sound as a way of assisting or enriching communication for someone, or offer the potentials of image making to create connection between people. entering into the arts form within a safe space and within a therapeutic relationship allows aspects of the client’s ways of relating to be experienced differently, or the client can experience themselves differently. this might, for example, be true as a client with autism experiences communication with, and relationship to, another through paint, compared to words. A number of arts therapists have stressed the importance of such participatory experiences of the arts in the arts therapies. it is this act of participation that can engender change through its experiencing rather than reflecting or describing alone: ‘through such a group there is the possibility of rediscovering experienced culture, not just receiving a passive and often processed observation’ (Jennings, 1983: 49). All arts forms and expressions occur in a space that defines the way the art medium is experienced by the client. We have seen how this occurs within a creative therapy space and within a ‘triangle’ between client, therapist and art form or process.

twelve

The sensuous encounter: the arts therapies and the unconscious Introduction: the unconscious – definitions and encounters As he was falling asleep one night, André Breton heard his frst automatic sentence. The sentence was ‘There is a man cut in two by the window.’ He called it an automatic sentence because it came, he said, from nowhere, ‘like a knock on the windowpane of consciousness’. With it came a faint visual image – of a man with a window around his middle. Later, in 1919, he produced a book called Les Champs Magnétique. The frst section was called ‘The Unsilvered Mirror’. This title – a mirror that can be seen through – seems to talk of staring through into a world beyond the surface, suggestive of looking beyond the everyday experience of visible reality, into an area present, but normally unseen. Some have seen this as an image of encountering the unconscious. In the 1930s, artist André Masson scattered sand, spread glue and paint to create images quickly – trying to minimise the censorship he felt his conscious mind subjected his creativity to. He was deliberately trying to reach into parts of his mind he was not actively aware of. Others who worked around him likened this kind of practice to awake dreaming: to an act which tried to revolutionise people’s ideas and experience of reality by unleashing the power of a domain inside the self which was known as the unconscious (Conley, 2001: 105).

Ariadne’s thread This work was produced by Masson in the 1930s. It was one of a series of images produced by him through ‘automatic drawing’. The notion of automatic writing and drawing was to fnd a way to create the optimum state for material from the unconscious to emerge. It was akin to creating a dreaming state whilst being still awake. Ariadne is not guiding Theseus through the maze but seems to be embracing him. The labyrinth motif has been noted as a metaphor for the unconscious. This painting was bought by psychoanalyst Lacan in 1939.

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André Masson’s ‘Ariadne’s Thread’. Copyright © ADAGP, Paris and DACS, London 2004. Lacan was in a relationship with the sister of Masson’s wife. I mention this because it gives some sense of the connected worlds of analytic thinking and avant-garde art. As this chapter shows, this dialogue was an important one in the mutual development of both felds – of the arts and psychoanalysis.

Artists and analysts alike have tried to encounter, describe and understand the function and uses of the unconscious. Claims have been made for it as a major ‘discovery’, affecting many facets of living, from the arts to advertising to politics. Some of these claims maintain that engaging with unconscious material is vital in therapeutic change. Counter-claims have been made that the existence of the unconscious is an unprovable proposition: a hypothetical construct which has no basis in fact. The idea of the unconscious has been central to some approaches within the arts therapies: their thinking and their methodology. Metzner, for example, says that the basic underlying assumption in ‘psychodynamic music therapy’ is the ‘existence of, and dynamic processes within, an unconscious part of the mind, which has an influence on intrapsychic and interpersonal processes within and outside of the musical activity between the therapist and patient’ (2016: 1) This chapter will explore the notion of the unconscious in relation to the arts therapies and to their concepts of change. Can

160 Agents of transformation   we, for example, say that there is any proof that the act of painting can achieve a relationship to the unconscious? If this relationship can exist, can it bring about positive change? Can we say that sound has any connection with unconscious processes? Is there any evidence to tell us whether working with enactment or dance connected to a ‘forgotten’ or suppressed traumatic experience can bring about recovery? For some arts therapists all these questions revolve around the relationship between the unconscious, therapeutic processes, arts activities and the bringing about of positive change or development. In her interview later in this chapter, Canadian art psychotherapist Josée Leclerc, illuminates the dynamic intimacy between these areas. In speaking of her work and identity as artist, art therapist and psychoanalytic psychotherapist she comments that: ‘I feel that these three domains have become progressively integrated; so much so that it would be difficult for me to identify the impact each one separately has on my “sensitivity” to the unfolding of unconscious manifestation and my capability to work (or “play”) with it in order to assist clients in the road toward self-awareness.’ At the heart of such connections is an assumption which is central to a significant number of arts therapy approaches. This is that there exists an aspect of the self which can be described as ‘the unconscious’, that connects with certain problems which cause distress or dysfunction. This assertion is followed by another: that there are ways of engaging with the unconscious which can bring about change or healing. Art making and arts products within the therapeutic process are seen to relate to the unconscious in ways that are fundamental to the recovery of health, or the improvement or maintenance of well-being (Hougham and Jones, 2017). What are these ways? How do arts therapists see the unconscious? Does it exist? In the encounter between arts therapist and client how can the unconscious feature? Not all forms of arts therapies work with the unconscious, or with a model of identity which acknowledges the existence of the unconscious. These have been discussed in Part II and will also be looked at in Chapters 14 and 15. As described in Chapter 4, for example, some forms of music therapy concentrate their attention on the physiological changes brought about in clients when they are in contact with music. An example of this is Toson et al.’s (2014) work in a university hospital in Kayseri, Turkey, where they conducted a randomised controlled study to determine the effect of music therapy (Traditional Turkish Music), aromatherapy and vibration application on neonatal stress and behaviours, concluding that the application decreased stress in newborns. However, a significant proportion of work is centred within a psychodynamic approach in which the notion of the unconscious features. Karkou’s (1999a, 1999b) research into the main theoretical influences within the UK arts therapies, for example, indicated the prevalence of the work of Winnicott, psychoanalytic theory, object relations theory and the work of Jung and Klein. The extent of this varies within the different disciplines; for example the influence of the analytic school is more prevalent within UK art therapy than dramatherapy (Valente and Fontana, 1993). Research by



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Holmqvist et al. (2017) explored thirty-eight Swedish art therapists’ perceptions of the nature of change for their clients. This included the therapeutic relationship or alliance; creating; playful experimentation; changes in selfawareness and the concept of the unconscious. One of the themes concerned ‘inner change’, with a therapist describing the therapeutic relationship and image in the following way: It is probably in the image that I can see if there has been an inner change . . . For me it is also a process of a series of images where one can see a recurring pattern or form. When looking at it together with the patient, it is possible to grasp what is happening inside the patient and be able to talk about it. (Holmqvist et al., 2017: 48) Holmqvist et al.’s summary of the therapists’ reflections on the role and nature of the unconscious notes the concept as connected to exploration, image and relationship and as concerning: changes when patients explore the painted image and their emotional life . . . Therapists expressed this as “the patient suddenly saw their own images” or “the patient stopped and really saw the image” . . . ways of describing exploration were unconscious material becoming conscious and self-discovery. The reflective dialogues could be based on the content of the image or the feelings it evoked. Creating can also occur by exploring the colours used, the shape and placement of the motifs, and their direction in relation to each other. (Holmqvist et al., 2017: 48) This chapter looks at the ways in which arts therapies practice relates to such concepts of the unconscious, and how arts therapists understand it in relation to the complex relationships between the therapeutic process, arts making and creativity.

Analytic perspective Towards the end of his career Freud described the unconscious in this way: The oldest and best meaning of the word ‘unconscious’ is the descriptive one; we call a psychical process unconscious whose existence we are obliged to assume – for some such reason as that we infer from its effects – but of which we know nothing. In that case we have the same relation to it as we have to a psychical process in another

162 Agents of transformation   person, except that it is in fact one of our own . . . we call a process unconscious if we are obliged to assume that it is being activated at the moment, though at the moment we know nothing about it. (Freud, 1965/1973: 102) This quotation is typical of what often happens when the unconscious is described or discussed. An attempt is made to try to define something that is, by its supposed nature, elusive and hard to determine by words, by cognitive thinking and concepts. We ‘know nothing’, Freud says, for example, yet we must ‘assume’ that it is there. A number of themes arise from this definition which all relate to this elusiveness. They are central to the relationship between the unconscious and the arts therapies. The self is seen as divided: Freud’s description is of a psychic existence which is at the same time both a part of us, and yet unknown. He uses terms to describe the unconscious that create a seeming paradox: it is both of us, and yet it is as if it is not us. We know of its existence and yet do not know directly of its existence: at the same time ‘we know nothing’ and yet we must, we are ‘obliged’ to assume that it exists. This ‘must’ is because unconscious forces are at work, and are manifested – they have ‘effects’. Yet we cannot see the origin, the unconscious, directly. We can infer only from signs, effects, that it exists and is active. The theme of the unconscious as an area, a region is also here; Freud goes on to describe it as ‘a mental province rather than a quality of what is mental’ (Freud, 1965/1973: 104). These different areas are given names, attributes and relationships with each other: ego, superego, unconscious and id. Part of psychical illness is seen to occur when the relationships between the different regions of the mind becomes problematic. The act of analysis is one whereby the ego’s field of vision is widened; it can appropriate that which is buried in the unconscious: ‘It is a work of culture not unlike the draining of the Zuider Zee’ (Freud, 1965/1973: 112). Here the theme of a region or geography is continued – the image is one to which I will return – of the therapeutic act being likened to an act of transforming the landscape; draining an area of the North Sea, of uncovering, making something visible. Some see anxiety as central to this process. We are seen as organisms who structure our lives defensively to avoid anxiety. Anxiety is: not only a painful bodily sensation, but [it] can interrupt thoughts and intentions leading to disorganisation of moment to moment behaviour. When extreme, anxiety can lead to feelings of disintegration and threaten the sense of being a whole person. All psychodynamic viewpoints share the notion that our central identity, whether we call it ego or self, has to be constantly defended against anxiety in order to limit disruption and maintain a sense of unity. (Thomas, 1996: 284)



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These defence mechanisms such as repression, denial and projection are seen as part of our normal psychological mechanisms, but they are largely unconscious, we are not consciously aware of them. Traditional Freudianism draws a ‘metaphorical “horizontal” divide between consciousness and that which is pushed down into the unconscious’ (Thomas, 1996: 312). Others within the analytic tradition have emphasised different aspects of the unconscious. Winnicott, for example, has argued that in some situations in infancy the ‘true self’ has to be hidden deep in the unconscious, and protected by a conscious compliant version of the individual called the ‘false self’ (Winnicott, 1974). Jung critiqued the idea of a unitary ‘self’, and the unconscious is seen by him as a part of this questioning: ‘the so-called unity of the self is an illusion . . . We like to think we are one, but we are not, most decidedly not . . . I hold that our personal unconscious, as well as the collective unconscious, consists of an indefinite, because unknown, number of complexes or fragmentary personalities’ (Jung, 1935: 81). Some have challenged Freudian views of the unconscious as too negative. Storr (1972), for example, says that because Freud’s initial work was with hysterics, this tainted his view of the unconscious and explains why it is mainly a repository of ‘unacceptable’ material. This view has been contrasted with the role of the unconscious in creativity where it can be seen as playing a role in inspiration and motivation for making. Again, as we shall see, this way of critiquing Freud is relevant to the ways many arts therapists understand and relate to the idea of the unconscious. Jung, in Archetypes and the Collective Unconscious, refers to the unconscious in relation to a client, Miss X: Long experience has taught me not to know anything in advance and not to know better, but to let the unconscious take precedence. Our instincts have ridden so infinitely many times, unharmed, over the problems that arise at this stage of life that we may be sure the transformation processes which make the transition possible have long been prepared in the unconscious and are only waiting to be released. (Jung, 1959: 100) Here themes of connections between instinct and the unconscious have a different relationship from the qualities that Freud attributed to the unconscious. Stress is placed on the notion of an innate wisdom based on experience, and that the unconscious is a place where material is stored which can be accessed to support an individual during crisis. Within this framework the ‘collective unconscious’ can be expressed through contact with archetypes. These are present in the expressions and the power of phenomena such as dreams and myths. Abbenante and Wix argue that the arts therapies within this framework assist a client into reverie and imagination, for art therapy ‘encouraging play with the possibility in an image’ (2015: 37). As art therapist Schaverien says, the idea is that

164 Agents of transformation   archetypes do not take on form, but are ‘the underlying element which influences the choice of a certain image at a particular time’ (Schaverien, 1992: 21). The reasons for the activation of certain archetypes at a specific time for individuals vary. Schaverien notes that Jung, based on his own experience and that of his patients, considered that making pictures was a useful method of accessing the healing potential of the unconscious. He encouraged some of his patients to paint ‘in order to escape the censor of the conscious mind’ (Schaverien, 1992: 21).

Artists and the unconscious Though the idea of the unconscious had existed before Freud began his work, the infuence of his specifc ideas has permeated the feld of therapy and the arts in many cultures. It’s tempting to say that ideas of and about the unconscious have come to the arts therapies only through the feld of psychoanalysis and psychotherapy. However, we can say that though analysis has exerted an important infuence on the arts therapies’ relationship to the unconscious, there are other elements to consider. The first point to make in relation to this is that the idea of the unconscious was extant in the arts prior to the work of analysts such as Freud and Jung. This heritage is something which the arts therapies reflect through their relationship to artistic expression and traditions. Another element concerns the arts in a ‘post-Freudian’ world. Numerous artists, writers, musicians and dramatists have described and shown how Freud’s ideas of the unconscious, in particular, have impacted on their work. These concepts have been influential in the ways in which artists have related to their media, their process and the relationship between themselves and their art making. The responses made by artists in different fields – from painters to film makers – to the ideas of analysts such as Freud or Jung have developed into independent discoveries and findings about the unconscious. Sometimes these initial responses by artists were based on general ideas, or even misunderstandings, rather than on actual reading of Freudian or other analytic texts. These ‘mistakes’, however, have sometimes created interesting and valuable contributions to our perceptions of the unconscious. They reflect their creator’s discoveries, the initial Freudian idea, or the mistaken notion of what Freud was saying, for example, serving as a starting point or prompt for the development or expression of a different idea. This can be seen in one of the chief groupings of artists in dialogue with ideas about the unconscious – the Surrealists. Many artists in this group were ‘influenced’ by Freud’s ideas of the unconscious: in their theories, the forms their creative products took, and in the actual process of creation. They deliberately attempted to revolutionise their ways of working. For example, as described earlier, artists such as Masson tried to reduce conscious control in their writing and drawing. Not only did they record and use images from dreams, but also they tried to create a dreamlike state in the techniques they developed to make art or to write. This was in order



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to reflect the unconscious arena of the undirected and uncensored. Their concern was often with the idea of the unconscious as a source of ‘unbound’ energy, relatively free from censorship (Mundy, 2001: 12 ref.; Breton, 1972). The Freudian notion of the mechanics of the psyche was often used as a way of framing their goals or mission. Artists echo his concerns in the titles and content of their images, Max Ernst’s Oedipus Rex for example, or his dream collages of Rêve d’une petit fille qui voulut entrer au Carmel. Films such as Un chien andalou (1929) and L’Age d’or (1930) or Dalí’s contribution to Hitchcock’s Spellbound (1945) work with ideas of dreamlike unconscious association as a way of moving through the film, rather than using a logical narrative. Surrealist manifesto and journal material often features analytic ideas and considerations alongside artists’ writings. The Erotika review published in Czechoslovakia, for example, featured work on Freud alongside texts by artists Aragon and Breton (Mundy, 2001: 239). Breton talks of the emergence of poetry as involving material struggling for expression in its journey from the unconscious as it encounters censoring: ‘What I have wanted to do above all is to show the precautions and the ruses which desire, in search of its object, employs as it manoeuvres in preconscious waters, and, once this object is discovered, the means (so far stupefying) it uses to reveal it through consciousness’ (Breton, 1987: 24–5). The Surrealists, whilst influenced by analytic ideas concerning repression, condensation and the work of dreams, did not merely accept these ideas uncritically. On the one hand their practice and artistic products created new dimensions to the cultural work of exploring and reflecting the unconscious – an additional route to that of psychoanalysis. Also, many artists rejected the goal of a cure, along with ideas of normality contained within the field (Mundy, 2001: 27). One of the appeals of their ideas of the unconscious is connected to their cultural and political goals. Their work was inspired by a rhetorical determination to revolutionise on a political, artistic and personal level. The ‘freed imagination’ was a stated goal – the restraints of culture or politics were to be torn away. The liberation of the unconscious and its arena of the unrepressed and uncensored was a part of this vision. One of their stated goals was to challenge the rational Cartesian world view, to liberate desires, feelings and impulses buried in the unconscious and to bring them to be incorporated into the accepted ‘allowed’ reality.

‘La Rue Surréalisme’ All arts forms were involved in this work. At the 1938 Exposition Internationale du Surréalisme the event took the form of several different environments, each trying to challenge the limits of everyday normality, normal social and moral codes. The ‘Rue Surréalisme’, for example, contained a massive grotto. One thousand and two hundred stuffed coal sacks were suspended from the ceiling, the undulating foor was covered with dead leaves, there was a pool, a brazier

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burning coals, immense beds and there was a soundtrack of laughter recorded at an asylum. On the opening night dancer Hélène Varel performed an ‘unconsummated act’ which included wailing, gyrating, wrestling with a live rooster on some of the beds, along with partial nudity and a torn costume. Here we can see the ways in which all the arts are present within the Surrealist event, the emphasis on a sensual engagement with the unconscious and an attempt to challenge the norms of the everyday ‘conscious’ world by unleashing their version of the unconscious.

Freud was in written communication with some of those involved in the arts in the twentieth century, though he often expressed bafflement about their practice. For example, he wrote to André Breton in 1932 that he had received many testimonies from Breton and other Surrealists that they were interested in his research. He went on to add that he was not clear what Surrealism was, nor what it wanted: ‘Perhaps I am not destined to understand it, I who am so distant from art’ (in Mundy, 2001: 75). Others from the analytic movement, such as Lacan, were close to Surrealist circles. Harrison and Wood point to analyst Lacan’s role in ‘mediating’ the Freudian theory of the unconscious ‘through his pre-war involvement with the Surrealist group to produce an account of the human individual which considerably privileged the act of looking: few ideas have proved more fruitful for later representations of human subjectivity than his “mirror phase”’ (1992: 552). Lacan, for example, published some of his work in the Surrealist journal Minotaure. We can see some of the common language, images and concerns shared by the Surrealists and Lacan – the relationship between identity, mirror, the conscious and unconscious – in the work of Masson at the beginning of this chapter (Lacan, 1969). The idea Harrison and Wood suggest is that Lacan’s engagement with the Surrealists had an effect on his influential ideas concerning self and other, image recognition and the infant’s relationship to looking at her- or himself in a mirror (Harrison and Wood, 1992: 552, 609). Lomas sums up the mutual incomprehension between Freud and Breton as not being to do with Surrealism’s misunderstanding of Freud’s work, but in its ‘imperative to change the world’. For the Surrealists, he argues ‘it was a matter of knowing not only how our dreams are shaped by the remote past, but also how they might be realised concretely in the future’ (Lomas, 2001: 76). Others have cited desire and sensuality as a key difference. Though the ideas attracted artists, they are said to have drawn back from the methods and ultimate goals of analysis. Whilst psychoanalysis recognises desire and the senses within the clients’ world, it prefers to see ‘its own practices as unmarked by desire, as if they were entirely governed by rationality’ (Le Brun, in Mundy, 2001: 308). In contrast the Surrealists believed that only an approach which was sensual, which engaged with the senses, could come to terms with the unconscious.



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Louise Bourgeois, ‘I Do, I Undo, I Redo’ These three towers, called ‘I Do’, ‘I Undo’ and ‘I Redo’, are made from steel, marble, fabric and mixed media, and were created between 1999 and 2000. They stand between nine and fourteen metres high and were constructed of spiralling staircases and stairwells. Commentators, and Bourgeois herself, have drawn attention to the infuence of analyst Klein’s ideas within the work. The spiralling forms have been

Louise Bourgeois’s ‘I Do, I Undo, I Redo’ (1999) installed in the inaugural exhibition of the Tate Modern at Turbine Hall in 2000. Collection of the Artist, courtesy of Cheim & Read, New York. Photo: Marcus Leith © Tate, London.

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described by her as: ‘the spiral is the study of the self’ (Bourgeois, in Warner, 2000: 18). The texts and images accompanying the towers, or built into the towers, deliberately create a dialogue with Kleinian ideas. For example, text written by Bourgeois relating to the ‘I Do’ tower contains, ‘I am the good mother. I am generous and caring – the giver, the Provider. It is the “I Love You” no matter what’ (Bourgeois, in Warner, 2000: 32). She writes of the ‘Undo’ tower: The UNDO is the unravelling. The torment that things are not right and the anxiety of not knowing what to do. There can be total destruction in the attempt to find an answer, and there can be terrific violence that descends into depression . . . It is the return of the repressed . . . I smash things, relations are broken. I am the bad mother. It is the disappearance of the love object. The guilt leads to a deep despair and passivity. (Bourgeois, in Warner, 2000: 32) In the ‘Redo’ a solution is found communicated in the text by notions of confidence, activity, reparation and reconciliation, ‘There is hope and love again’ (Bourgeois, 2000: 32). The viewer enters into or walks around the towers, meeting huge angled mirrors, chairs and staircases enclosed in metal. Sculptures of a mother embracing a baby, of a distracted mother with milk spouting from a breast and a mother connected to a floating baby by an umbilical cord are contained within bell jars in the body of each tower. Bourgeois’s art takes place in a culture that has appropriated the work of Klein and Freud. She shows this in the language of her work, her images and the process she creates for the viewer. These include, for example, Freudian and Kleinian ideas of object relations: of the mother as an early object of intense projections and splitting. In both Kleinian writing and in Bourgeois’s sculptures we can see, on the one hand, an idealised image of the ‘perfect’ mother whom we seek for and unconsciously reinstate in other relationships, and an equivalent image of the ‘bad’ frustrating mother, whom we defend ourselves against. A goal of psychoanalysis within this approach can concern a reintegration of this split: idealised and despised, good and bad. However, Bourgeois’s work is not a mere reproduction of analytic ideas about the unconscious. The personal iconography of towers, spirals, huge angled mirrors and encounter brings her own discoveries, her own world and her creativity to connect with and confront Klein’s ideas. She offers us her own artistic experiences and discoveries in a way that invites participation and active response.



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In this way, the arts have developed their own history of responses to the unconscious and to Freudian or analytic ideas. Artists such as Bourgeois have made their own discoveries following on from initial ideas by analysts such as Freud and Klein about the unconscious. Artists’ research and findings concerning the ‘unconscious’ are as valid to our consideration of the arts therapies as the developments of thinking and practice in the fields of therapy and psychology. Arts therapists Alvin (1975), Darnley-Smith (1996) and Tyler (2000) acknowledge the importance of twentieth-century work, such as the above, on the language and form of the arts therapies. Alvin comments, ‘Contemporary composers of the avant-garde act as explorers in a world of sounds and often provide us with strange experiences’ (1975: 104–5). This exploratory relationship continues, for example Linnel et al. working across the borders of art and art therapy with film, photography, drawing, painting, writing, installation, found objects and memorabilia explore the ‘internal’ world, ‘the intersections of memory and imagination’ by bringing ‘spaces that are generally experienced as private and interior’ into a shared social space (2007: 1). Darnley-Smith notes, in particular, that the possibilities of improvisation in music therapy have been influenced by the developments of twentieth-century musical movements. Particularly important have been those that have emphasised the potentials of atonality and free work, that do not require logical development, resolution or crafted composition, that are, rather, ‘raw and spontaneous’ (Darnley-Smith, 1996: 2). Tyler, writing about the development of music therapy, draws a direct correlation between contemporary forms of musical improvisation, and the way this opened up possibilities in accessing unconscious material. She speaks of the far-reaching changes in music, ‘the progression from the harmonic language of Wagner and Richard Strauss, to the atonality of Berg, Webern . . . the music of Messiaen, Boulez, Stockhausen . . . and especially Cage’ (Tyler, 2000: 385). These new forms and ways of working, improvising atonally, of self-expression are ‘the musical equivalent of free association’ (Tyler, 2000: 385). So, the arts therapies’ relationship to the unconscious is not just with the ideas Freud first articulated in the field of psychoanalysis. They also relate to developments in the arts, the way in which the arts have created and modified the notion of the unconscious as well. This relationship includes the modes of expression and languages used within the arts therapies. Put another way, the practice and methods of movements such as the Surrealists or musical work emphasising atonality or improvisation have influenced the artistic processes and languages within the arts therapies. Also, importantly, in their emphasis on the sensual encounter through the physical relationship with paint, clay, touch or sound, the arts therapies reflect the points made above about the discoveries and emphases in some twentieth-century arts movements on the physical sensual encounter with the unconscious. This involves working in a way that is not rooted in verbal language alone, but in the physical senses engaged in the arts (Hougham, 2013). The point here is that the arts therapies offer an additional aspect of

170 Agents of transformation   contact through the relationship between physical, sensual acts such as dance movement or sculpture and the therapeutic encounter with unconscious material. The next sections consider these particular ways of encounter and the arts therapies in more detail.

The dynamic unconscious The unconscious can be seen as linked to the ways each individual makes sense of the external world. The individual represents this external reality symbolically, inside, creating what Thomas calls ‘psychic realities and ultimately our selfhood’ (Thomas, 1996: 282). Within the differing frameworks which have developed in the analytic tradition, some have observed that all share a sense of ‘a self that is potentially divided’ (Thomas, 1996: 315). As mentioned, this is seen to have emerged from the Freudian model of the self, with its ideas of conficts centring on subdued desires repressed into the unconscious: of confict being subdued to try to create a sense of unity. In the analytic approach focusing on object relations, for example, there is particular concern with internal conficts and of fragmentation, of tension between identities introjected during childhood. As we have seen, within this approach consciousness is seen as partial, a filtered version of what we know and have experienced. As Thomas says, ‘Much that is meaningful and most that is motivating is hidden in the unconscious . . . consciousness, rational thought and agency are largely subjugated to the main driving force – the dynamic determining unconscious’ (Thomas, 1996: 283). According to psychoanalytic thinking human behaviour is largely determined by primitive motives which originate in the unconscious, and remain so deeply buried that we have no access to them, although we can gain partial access with the help of psychoanalysis. Because the unconscious is thought of as the source of motivation, it is called the dynamic unconscious. Unconscious motives are frequently in conflict with conscious thoughts and intentions. It is this dynamic unconscious which is ‘in control most of the time, playing out a drama in which the narrative is beyond awareness and the enactments are beyond conscious control of the experiencing subject’ (Thomas, 1996: 286). At heart most arts therapy work which frames its practice and theory in terms of an unconscious would echo these notions: of the unconscious as something which cannot be fully appropriated by verbal interpretation, or located at an original source. For example, the following ideas of both dramatherapist Grainger and music therapist Aldridge share these concepts. The arts therapies’ engagement with the unconscious is seen as dynamic, linking art making, the relationship with the therapist or with others, as a route to uncover and communicate; to create contact where there is disconnection and to allow healing to occur with material which is buried or split off. The notion, though, is not that the unconscious is fully appropriated. Rather, it is that material which has been located there is creating difficulty, and that this can be reflected or encountered through the medium of image,



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movement or sound, and the relationships between therapist and client or between clients within the therapy space. These contacts can reflect and effect, can establish communication and change. How does this occur? Why it is seen to be effective? How do different ways of framing and understanding the unconscious connect this to change? These questions relate to the ways in which arts therapists view the unconscious, and to their understanding and practice of how they work with clients.

How do the arts therapies position the unconscious? Various theories of the unconscious are represented within the arts therapies. Though some elements are common within the arts therapies’ consideration of the unconscious, differences in emphasis do occur. Dramatherapist Grainger, for example, says that because arts therapists use the imagination for sharing personal experience, ‘welcoming other people into what would otherwise remain private worlds, the creative therapies regard it [the unconscious] as an active presence rather than the simple projection of something inside people’ (Grainger, 1999: 14). He links this with a Jungian model of ‘psychic reality’. As the individual unconscious is differentiated from the collective reservoir of unconscious psychic life, the artistic imagination assumes the role of ‘intermediary between persons and the source of their person-hood’ (Grainger, 1999: 14). In contrast, Aldridge (1996) refers to Bateson’s theories of the unconscious and learning. Aldridge, in his consideration of consciousness and music therapy, says that in our relationships with others we exchange information about unconscious processes all the time. He allies art with this: ‘art is a form of behaviour which perfects the communication about how to handle unconscious material. In addition it has the ability to express the fact that we are dealing with the interface between unconscious and conscious material’ (Aldridge, 1996: 97). He describes how Bateson’s theory of the unconscious is centred on learning and habituation. As habits form, ‘knowledge sinks down to less conscious and more archaic levels’ (Aldridge, 1996: 98). This knowledge often contains painful matters that we do not want to look at, but also things with which we are familiar. The ‘economics’ of the mental system are seen to sink generalities of the relationship, which remain permanently true, into the unconscious, keeping conscious ‘the pragmatics of particular instances’ (Aldridge, 1996: 98). The relationship between music therapy and the unconscious here is seen in terms of economy. The conscious mind cannot be aware of every detail, but habit formation ‘has its price in terms of accessibility’ (Aldridge, 1996: 98). It is difficult to change or examine all material consciously – such central processes are difficult to express verbally or consciously. However, Aldridge argues, they can be expressed artistically and musically: ‘the skill of the artist, or rather the demonstration of his or her skill, becomes a

172 Agents of transformation   message about those parts of the unconscious, but not a message from the unconscious. Our challenge then is to provide a vehicle for the expression and articulation of that which is hidden’ (Aldridge, 1996: 98). As this demonstrates, arts therapists do not have a uniform view of the unconscious, but hold a variety of positions – this, in turn, will affect the experience of the client. By comparing these two views on the arts therapies’ relationship to the unconscious, we can see that, though some aspects are common to both of these arts therapists, there are also differences in orientation. This will impact both on the practice of the therapist and the experience of the client. Grainger, influenced by Jungian ideas of the unconscious, sees the arts therapy space creating access to collective aspects of the unconscious which are needed but not directly connected; a part of the process of healing or developing identity. For Aldridge, the arts therapy space connects with a way of seeing the unconscious as a part of a ‘re-creation’, of access to material which has been experienced or learned, but is not easily accessible.

Arts therapies practice and the unconscious The literature argues that the arts therapies can create particular connections between unconscious material and change. The connections form some of the particular qualities which the arts therapies offer within therapy. These develop from the ways in which the arts are seen by some as a particular kind of ‘messenger’ between the conscious and unconscious. The next section will look at these areas in relation to the unconscious: • • • • •

The process of art making and the created product, and the perspective offered by arts processes and products The arts therapies and the non-verbal The nature of the emotional experience of the client within the arts therapies The dynamic relationship with the therapist The play space.

A particular messenger: uncloaking, excavation and the unconscious The arts therapies are seen to offer specifc qualities in their relationship with the unconscious. There are a number of different elements within the way people see this. Some emphasise the ways in which the arts element of the process offers particular opportunities to the client. Carter (1992) and Howat (1992) argue that music can create a bridge between the ego, the temporal or the outer, and the psyche or ‘inner’ world: that musical language directly expresses the archetypal, the unconscious. Hitchcock (1987) has pointed out that Jung considered that music should be a part of



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every analysis, commenting on how music reached deep, archetypal material. Sobey (1992) goes further, and argues that music is a ‘short cut’ to the unconscious, that it moves through defences and touches us deeply and suddenly. Others echo this idea of immediacy and the ways in which arts processes can assist in working through defences in an accelerated and helpful way: Aiello (1994), for example, talks about how music communicates unconsciously with the power and speed of a lightning fash. Case and Dalley say that it is the presence of the art form that ‘creates the complexity and essentially the uniqueness of art therapy, and the intensity of the relationship is fundamental to the art therapy process’ (Case and Dalley, 2014: 52). They see the art in art therapy as a process of spontaneous imagery released from the unconscious. This notion can be said to be true of all the arts therapies. They, as the music therapists did, parallel it to the process of free association and dream analysis used by Freud: giving access to unconscious chains of association and the ‘unconscious determinants of communication’ (Case and Dalley, 2014: 52). However, they contrast art therapy to processes such as free association, as a painting or sculpture is concrete and can take on a life of its own. An object is made and remains present, unlike in verbal free association or the analysis of a dream. Birtchnell (1984), similarly, draws an analogy between arts processes in the arts therapies and dreaming. He relates this to Freud’s idea of the processes of censorship that occur within the individual. This censoring controls what we allow ourselves to be aware of, and there exists an ‘interplay between the pressing forward of suppressed emotions and the pushing back of the censor’ (Birtchnell, 1984: 33). Material suppressed to the unconscious is expressed owing to the ‘slackening off’ of the censoring – these are played out in fantasy, and the dreams camouflage this material through ambiguous images, changing identities. The creation of artistic products within the arts therapies is seen not simply to allow access to material related to the unconscious. As Schaverien says of art therapy: When a picture is made in therapy it may ‘uncloak’ an image of which the artist was previously unconscious. Once such an image is pictured it is ‘out there’ rather than internal; it can be seen and this effects a change in the unconscious state, in the artist, to a more conscious one. As a result of this, even without verbal interpretation, a transformation begins to take place in the inner world of the artist. (Schaverien, 1992: 7) Schaverien identifies a crucial aspect of the arts therapies’ relationship to the unconscious. The notion here is of a move from being ‘cloaked’ to ‘uncloaked’. The being ‘seen’, as the image emerges, is part of being ‘out there’ rather than being held internally. Even without interpretation this creation of the artistic product is a therapeutic act purely by its creation within the therapeutic space. The idea is that the creation of the art is accompanied

174 Agents of transformation   by an effect on the ‘internal world’, as internally held material is moved into the external world and is experienced by the client and therapist. Another aspect of this externalisation of internally held matter through a shared product is described in terms of ambiguity. Ambiguity can occur, says Birtchnell, in telling or writing a story, play or poem about someone who feels as you do, or who is given permissions that you do not give yourself. In art therapy there is ‘more scope for ambiguity, since you can represent yourself as an animal or even an object’ (Birtchnell, 1984: 35). Unlike dreams, the art therapy painting or object can be presented physically for others to witness. The creation of images which partially express or represent latent or suppressed material can allow their more complete integration into the personality: ‘allowing and owning the less acceptable aspects of oneself means that less energy is spent on denying their existence’ (Birtchnell, 1984: 39). In these ways, the process of art making and the products created are seen to offer specific qualities in their relationship with the unconscious. Here, then, arts therapists argue that the experience of arts work in therapy can be one of ‘uncloaking’ material relating to the unconscious. In some cases the creation of the art work, whether dance or painting, is one of ‘lightning’ – of a particular speed or directness, due to the reduction of conscious censoring which can be a part of creativity. They speak of a particular intensity that accompanies the experience of expression and encounter through the art form. If the artistic process within the therapy results in a product such as a painting, photograph, recorded music, script or video of dance, it is something that has a concrete, maintained witnessed presence – unlike a dream or a verbal association. The ambiguity of the artistic representations and their physical presence in front of others or the therapist can also offer opportunities for integration.

Arts process and non-verbal experience Thomas has compared the ‘psychodynamic’ approach to other psychological perspectives and concludes that there is more emphasis on pre-verbal and non-verbal modes of communication. She gives examples of this – concerning the emotions, early forms of thinking, and the persistence and survival into adulthood of infantile and highly charged forms of internal representation. She argues that any consideration of the impact of society on individuals has to take account of the fact that: by the time language arrives, most of the influential events have already happened and most of the structure of the mind is already laid down. Language will elaborate experience but, according to many psychodynamic theorists, language, in particular for the purpose of relating to others, is an impoverished medium whose precision in factual



  The sensuous encounter 175 domains fails to make up for the loss of more primitive kinds of communication. (Thomas, 1996: 291)

The importance is less on words but on the emotional charge they carry, and on the way they are used, ‘ways which tap into more primitive and unconscious processes’ (Thomas, 1996: 291). She later adds that some feelings and images often seem to be ‘beyond or apart from language’ (Thomas, 1996: 294). There are individual variations in the experience of the inadequacy of language, feelings or images that cannot be expressed in words, and these may reflect material that pre-dates language. For example, difficulties in speaking about a feeling or experience may be a defence against a painful memory. Sometimes this will be a manifestation of an unconscious process (such as a defence), but it may also be because the material is not easily connected to words. However, the arts therapies, through the non-verbal aspects of their practice, can offer clients the capacity to work in ways that are ‘beyond verbal language’. The capacity to work through embodiment, movement and dance, music, or through clay, paint or video can offer a medium and an arena where work can take place without words, and without the kinds of mapping or thinking related to verbal language. Experiences which were non-verbal can be reflected more easily, and a means can be created to engage with them where verbal language might hinder or render the contact or work impossible. Shapero, for example, in discussing the ‘musical mind’ considers areas such as the ‘mechanism’ of tonal memory and composition, talking about how a great deal of what is heard becomes ‘submerged in the unconscious’ (Shapero, in Ghiselin, 1952: 50). Within this process sounds or rhythms are linked with experiences. He describes what he calls the ‘creative unconscious’ which renders music ‘more than an acoustical series of tones’; what is heard becomes submerged in the unconscious where it is ‘compounded with emotional experiences’ (1952: 50). For maker of music and listener alike, emotions are evoked through this connection. Both parties are not consciously aware of the connections, however, but the psyche holds such connections unconsciously, and feelings are evoked by them without conscious connection. McDougall (1989), Jones (2007) and Wood (1998) have discussed the ways in which the body can hold memories and experiences which are not easily described or encountered through words and through cognitive processes, and which can best be accessed and explored through the non-verbal means of movement or physically based drama or art work.

Therapist comment Arts therapist James describes her work with a client with learning disabilities who could not communicate his experiences and feelings

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using words. The man had, in a short period of time, lost both parents and he had moved into residential care as a consequence. He is described as withdrawn, depressed, refusing contact and had lost weight. After a number of weeks where a relationship is built, both with the language of the arts therapy, and with herself as therapist, she describes a session as follows: He began to make quite loud and free sounds with movement. I joined him using the same pitch, the same intonation and attuning to the emotions I could hear in his voice. In response the sounds grew and he began to make bigger and bigger noises until eventually he roared with feeling, he shouted loudly, and banged the drum hard with his hands, the ground hard with his feet. His frustration, rage and anguish were apparent . . . I too banged a drum alongside and joined his stamping affirmatively. (James, 1998: 24)

You will see from the comment in the box that the therapist attempts to mirror the client’s expressions. In the description of the session she assumes that these expressions are concerned with rage and grief. The client, because of the nature of their disability, is not able to verbally confirm or deny this connection. However, the therapeutic space serves to allow him to use voice, music and movement to create expression. The therapist’s assumption is that the client is finding a way to contact and express feelings which had been repressed, and which had not been able to find a form or route. James says that her therapeutic approach was that ‘the client [could] understand, if not consciously then at least unconsciously. If he was willing to allow me, I just wanted to feel, to sense, to intuit my way into his internal landscape’ (James, 1998: 24). This could be seen as an intrusion; however, the therapist acknowledges this and tries to act in a way which is as sensitive as possible. The work here relies on the idea that the art form and the relationship with the therapist enable a communication to occur. The internal world finds external expression. Relief is in the expression and connection that the art form permits within the safety of the therapeutic space and relationship. There may be a cathartic or releasing element that the art form facilitates – the internally held-in feelings are vented. The expression and containment may give some relief to feelings that have been suppressed and therefore held on to. This holding and suppression is understood to cause part of the client’s distress. The client’s internal world is seen to be reflected in the work. Words would not have been an option in this situation, and the arts therapies offer a way of enabling feelings repressed into the unconscious to be made accessible.



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By accessing the unconscious ‘world’ through its reflection in the art forms of movement, music and vocalisation some relief of the client’s difficulties is seen to be achieved. Reflecting on the practice, James says that the quality of contact between client and therapist can ‘deepen profoundly’ when relationships are made without words, and that a depth and range of human experience can be encountered through music, movement and touch (James, 1998: 22). Here, then, is an example of how the artistic medium and the relationship with the therapist, whether in improvisation, movement, drawing or music, can enable the expression and exploration of material that might not be verbally engaged with by a client. The space and language of the arts therapy session can allow such possibilities (Snow et. al., 2017). Particular sets of emotions can enter the therapeutic encounter as the client is involved in the anticipation, making and aftermath of creative work, expression or creation. Some have argued that it is necessary for words to be used to help assimilate such experiences into the conscious mind. Others argue that there is no need to verbally reflect upon or analyse the experience. Still others would argue that the dichotomy between thinking, reflecting and cognition versus emotion, sensation and intuition is a false one. Courtney (1988), for example, talks about knowing with the body. Still others would argue that there is a simultaneity of emotion and reflection, or that any separation between the two is not useful. Landy (1993), for example, talks lucidly about the goal of a balance within the therapeutic encounter. This is not an ‘either–or’ situation – it is not that arts therapies do not encompass verbal language or cognition. It is rather that there are aspects of the client’s experience or identity which can be accessed through the arts element of the therapy, and which can be encountered because they are not primarily mediated by cognition. In addition, for some clients who are not verbal, and for whom verbal therapy would not be possible, the arts expression can enable therapeutic encounters with material related to unconscious processes or content to occur. Some clients with learning difficulties might be included within this area, for example (Jones, 2007). Also, for some clients for whom verbal language encourages too cognitive a response, where always adopting an intellectual analysis of their lives can become a defence, the artistic means of encounter can provide a way of working which enables a freer, less cognitive experience. The arts therapies, then, in these ways enable particular kinds of access to experiences to occur, allowing encounters and explorations within the therapy which are evoked and held by the artistic medium and the relationship with the therapist.

Emotional encounter Wiser et al. (1996), in researching psychodynamic therapy, consider the emotional state of the client within the therapy space. They draw conclusions which seem to indicate that when clients are in ‘emotional states’

178 Agents of transformation   within the therapy, ‘deeper and perhaps more enduring shifts occur for them’ (Wiser et al., 1996: 125). They say that this may be due to the client’s cognition, which can be more susceptible to change owing to the heightened emotional state. The state can bring suppressed or repressed ‘historical’ material into the present within the session, and issues can be more effectively addressed and integrated. They say there is mounting evidence that ‘facilitating clients’ affective or emotional experience of their issues can lead to positive shifts for them . . . a move away from “talking about” their affective experience, to an inthe-moment “experiencing of” affecting experience is critical’ (Wiser et al., 1996: 125). They advocate a range of therapeutic experiences that facilitate in-the-moment emotional experiencing. These include attention to bodily cues such as clenching fists, tapping feet and concentration on the ‘here and now’ physical feelings of the client. The arts therapies can be said to have specific ways of operating with such notions of in-themoment experiences by means of their opportunities for artistic expression and activity that enhance or offer particular routes to such emotional states. Examples of this include the ways in which a re-enactment of an experience through drama can re-create strong feelings which are experienced physically in the bodily encounter of a role-play (Landy, 1993). Here a client might work in a group which re-creates a scene from someone’s life. The physical and imaginary recreation often leads to strong feelings. These are enhanced by the physical replaying and embodiment of the problematic situation. Repressed feelings that would not be allowed expression in everyday living can be expressed in the safety of the reenactment in the dramatherapy space. Similarly, in dance movement therapy the embodied exploration can activate and enable the connection and working through of feelings rooted in bodily experience in a powerful way (Dokter, 2016). This encourages and contains strong emotions within the therapy session. The capacity of art forms and ways of working to combine both the allowing of strong emotions and containment of those emotions in a form of artistic expression is related to the above ideas of the importance of emotional encounter within therapy. Oatley’s brief summary of the nature of change in the relationship between the conscious and unconscious within a Freudian therapy offers an interesting perspective on this idea. He says that, for Freud: therapy was the tracing of associations to their intersections and proper terminals, so that a sense of what the original and undisguised feelings and desires were might emerge. By readmitting them to consciousness, they would again become the person’s own: the person’s self rather than a symptom of not-self . . . to gather up those more troublesome aspects of the self, the disowned parts – mistakes, lapses, symptoms, until these too can be admitted



  The sensuous encounter 179 to the space of mind: owned, admitted to consciousness, so that people might know themselves. (Oatley, 1984: 42–3)

Seen from this perspective some argue that the arts therapies draw on the particular capacity of the arts to reflect, contain and transform material relating to the unconscious. When powerful, previously repressed material is allowed to emerge through the expression of the art form, it can be admitted to consciousness in the way Oatley describes. They argue that there are particular qualities which arts forms offer which are different from purely verbal therapy. Grainger, for example, relates the arts therapies to Freud’s notion of the role of the unconscious in a way that highlights a particular capacity of the arts within the therapy. He cites Freud’s idea that vital psychological adjustments which involve the acceptance of ‘powerful realities’ are struggled with at an unconscious level until they can be brought into some bearable relationship with conscious awareness. Grainger asserts that this ‘readjustment’ is something which the ‘arts therapy environment’ tries to allow and contain: ‘to allow because of art’s ability to contain powerful and disruptive feelings in a way that disarms the urge to deny their presence’ (1999: 131). He goes on to discuss the relationship between arts therapy processes and rites of passage as an example of this, citing authors who draw ‘attention to the creative chaos at the rite’s centre by means of which an existing psychosocial context is effectively destroyed so that a new and as yet unknown world of personal and social experience may come into being’ (Grainger, 1999: 131). Various arts therapists have described and analysed this aspect of artistic or cultural form and process. This basically says that art forms function in ways that enable expression, but do so in a way that both encourages and holds the material. The following is from an art therapy session. Therapist McClelland is working in a small group who ‘came together to explore and share difficult, emotionally charged experiences’ (McClelland et al., 1993: 116). In an early session one of the group members, Ann, has drawn graphic images of her experience of rape and violence. Another member, Pat, comments on Ann’s work that:

Client comment Ann did not seem to be drawing from her head. She sketched and moved over the paper in a way that did not seem pre-planned. ‘This was a real breakthrough for me, as I believed that no one could draw without planning it frst. I decided to have a go. I shut off my head and just went with how I felt . . . I did not know what I would draw, but I found myself drawing a door . . . After the door, I drew a tiny fgure [me] and a large fgure [the father]. I noticed that I had drawn

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his hands very large and claw like. I felt physically sick but carried on drawing. I began to hurt from the hands and scribbled them out very frmly. I actually felt the hands doing things to me that I hate. At the top of the paper, I drew two large fgures of almost equal size. I was very, very careful to get them the same size. It was to represent me and him, and the equality I feel I am now looking for’. (McClelland et al., 1993: 119)

The commentary on this, written collaboratively by therapist and client, is that Pat had switched from a focus on the verbal and auditory, to movement and the production of imagery. This is accompanied by strong feelings that are described as ‘re-accessing’ the actual physical pain and hurt of the original assault. At the same time, though, Pat has created an image and is relating as both creator and witness to the painting. McClelland notes the intensity of Pat’s gaze and encourages her in the act of looking. In reflection Pat says that the process enabled expression, in-the-moment feelings and containment: she had never before been able to articulate and explore her feelings, her experience and her awareness (McClelland et al., 1993: 121). The argument is that the art form and the relationship with the arts therapist in an encounter such as this acts as a particular form of container which allows a particularly powerful way to both evoke and contain. If the ideas of Wiser et al. are accepted, then the presence of strong feeling in this way, combining expression and containment, can powerfully add to the efficacy of the way the client utilises the therapy space.

Dynamic relationship There is a dynamic relationship between the arts therapies and the unconscious – it is not just about making the unconscious known. Schaverien has described the inadequacy of the situation in art therapy, for example, where this dynamic aspect within the process is not addressed suffciently: ‘The picture may then be reduced to a mode of description of a state, or an illustration of the transference’ (Schaverien, 1992: 7). She refers to a crucial part of this dynamic as concerning ‘the central role of the picture as a vessel within which transformation may take place and this involves the picture as an object of transference’ (Schaverien, 1992: 7). This can be said to be as true for the dance movement, enactment or music created by the client. Case and Dalley indicate some of the elements of this process: Art therapy involves using images to facilitate the unfolding and understanding of psychic processes. It is not so much



  The sensuous encounter 181 a matter of art making the unconscious, or to widen and strengthen the ego, as of providing a setting in which healing can occur and connections with previously repressed, split off and lost aspects of the self can be re-established. (Case and Dalley, 2014: 53)

Schaverien refers to Jung’s separation of the production of art or images for therapeutic purposes and the pictures created as ‘art’. She draws attention to the former’s parallel with Jung’s idea of the active imagination. Active imagination ‘is an active production of inward images’ (Jacobi, 1967: 163, in Schaverien, 1992: 81). The individual is encouraged to move to their unconscious and watch and observe the contents to integrate them with consciousness. However, she notes, importantly, that ‘a picture is not a mental image; it is a picture. A picture has certain ways of interesting, influencing and affecting the people who view it’ (Schaverien, 1992: 82). The expression makes a dynamic connection between ‘inner’ and ‘outer’. The internally held material is expressed; in addition the expression and the made artefact affect the inner world, the unconscious. All these elements, the made product, the making process, the relationship with others and with the therapist are part of this dynamic. Material is expressed, brought into the arena of the therapeutic space and the relationship between the client and therapist. All elements interact together.

Play space and the unconscious Creativity has been understood in a number of ways. Hayes, for example, places it within the framework of being able to produce new ideas or approaches: ‘one of the most important mainstays of a technological culture’ (1994: 136). In a review of defnitions of creativity she notes that creativity involves escaping from conventional modes of thought or assumptions, linking this to novel styles of thought or originality in problem solving. She goes on to consider this within attitudes to thinking and representation, comparing Hudson’s identifcation of two different cognitive styles: convergent and divergent thinking. Based on a study of schoolboys and their approaches to academic work, convergent thinking tended to focus tightly on particular problems and seeking answers within existing frameworks, divergent thinking ranged widely in searching solutions, venturing outside usual frameworks. Reflecting or accessing unconscious material in the arts therapies space allows it to come into contact with the creativity of the client, and the opportunities offered within the creative work with the therapist. This material may previously have been held hidden or suppressed. By being allowed into the artistic opportunities within the therapy, the material can be opened up to creative possibilities. Imagery or expression can be played with, explored, extended or developed and re-framed. The client can be involved with the creative act of movement, painting or drama, or engaged in working with

182 Agents of transformation   the creativity of another or others, whether this is the group or the therapist. This allows held unconscious material to be open to creative ‘divergent’ opportunities and possibilities.

Jung’s building games In Memories, Dreams, Refections Jung (1961) discusses the emergence of his thinking in ways which involve the arts and their relationship to the unconscious. He talks explicitly about the importance of a childhood memory. This concerned his playing ‘passionately’ with building blocks, mud and mortar. This is accompanied by strong feelings: ‘I distinctly recalled how I had built little houses and castles, using bottles to form the sides of gates and vaults . . . These structures had fascinated me for a long time. To my astonishment, this memory was accompanied by a good deal of emotion’ (Jung, 1961: 197). He draws a conclusion, that the small boy is still around and has the creative life that the older Jung lacked. So, he begins to collect suitable stones and to play ‘childish games’, building cottages, a castle, a village. The mature analyst spends time playing, with breaks to see his clients and to have meals. During the activity he says his thoughts began to clear and he discovers an ‘inner certainty’ that the playing and building was helping him discover what he calls his ‘own myth’. The building game is accompanied by streams of fantasies that he writes down. He goes on to describe how his work, thinking and own healing grew out of the creation of such stone structures; internal images and fantasies are expressed in them: ‘had I left those images hidden in the emotions, I might have been torn to pieces by them . . . I learned how helpful it can be, from the therapeutic point of view, to find the particular images which lie behind emotions’ (Jung, 1961: 201).

A key part of this is that in the arts therapies something can be represented and yet it is not that thing. Birtchnell points out that a picture of a person or a thing is not the same as the person or thing, and yet carries some of their characteristics (1984: 41). It represents a ‘half-way stage’ – the client can shout at, or accuse, the representative image or enacted representation of a person in a manner that would be difficult to do face-to-face. This combination of distance and encounter is a part of the way the playful space of the arts therapies permits particular opportunities for unconscious material to be encountered and worked with. This will be considered in greater depth in Chapters 13 and 14. The arts therapies can be seen, then, as a way to reflect, encounter and transform unconscious material that is part of a problematic situation for the client. The nature of the arts experience and relationships within the



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arts therapies is seen to offer specific opportunities. The arts products and process alike are seen to be a way to reflect and transform unconscious material. Importantly, though, the process is not just to do with the creation of opportunities for access. The process of expression and the process of creativity along with contact with others, or the therapist over time, are seen as crucial to the process of change. From this develop questions concerning meaning. Can we say, for example, that there is a specific artistic language of the unconscious that can be understood? The next section will focus on the way in which meaning emerges in the arts therapies’ encounter with the unconscious.

A dictionary of the unconscious? Can there be a language of the unconscious? Can images, movements or sounds which seem to refect the unconscious be translated? Can there be a lexicon of the artistic expressions of clients? Can there be any conclusions drawn about their state of mind from the way someone makes an image? If, for example, a client makes a specifc set of expressions musically, expresses themselves through movement, character or specifc ways of drawing, can we make conclusions through diagnostic readings of internal problems in the unconscious? This has been a concern for some arts therapists. Opinion varies. As we’ve seen, some would question the basic idea that this connection assumes, for example, the existence of an internal world or the unconscious. Such questions relate to the ways in which arts therapists and clients can understand the expressions made or created within a session. The existence or formulation of a kind of lexicon, some argue, could contribute to therapeutic work by assisting the understanding of the communications processes at work within an activity. Diagnostic possibilities in the arts therapies have been linked to such expressions, and the capacity to ‘read’ them, for example. Therapist, therapeutic organisation and client could draw conclusions about a client’s state of mind owing to assumptions about movements, images or other artistic expressions made by clients. This is based in the gathering and analysis of previous experiences and expressions made by clients. McNiff states that it is the ‘diagnostic approaches’ to art therapy which have shown the most consistent ‘tendency to analyze visual data’ (1998: 92). His critique of this body of work is that ‘visual phenomena are reduced to principles of largely unrelated psychological theories. The art diagnosticians identify visual phenomena but quickly transfer them to verbal constructs’ (McNiff, 1998: 92). Some have criticised models of the arts therapies involving such diagnostic work as inherently problematic. Dramatherapist Milioni argues, for example, that ‘psychodynamic approaches . . . have been criticised for an abuse of power, when the therapist positions him/herself as “expert” in the therapeutic encounter . . . [which] makes it hard for the client to resist the expert discourse or version of truth . . . the therapist hijacks their story’ (2001: 11).

184 Agents of transformation   An often expressed idea linked to this criticism is that it is impossible to accurately read one person’s expressions in the light of others. Each expression is seen as a unique amalgam of specific life experiences – so that meaning can only be drawn from the specific image and that this can only be found from, or with, the individual client. Arts therapists such as Schaverien (1992) often use metaphors of diving, digging and excavation when referring to artistic expression and the unconscious. Their descriptions and analysis create an endeavour where therapist and client together are engaged in the task of uncovering, or allowing the expression of buried, covered or layered material. The expression made within the relationship between client and therapist and through art making is seen as one that is akin to archaeology – digging, allowing something to emerge from the ‘depths’. What does this metaphor reveal? Can it be trusted or justified? Is it valid or effective? Is it a structure placed upon individuals and on therapy, rather than something that is actually present? As described earlier, arts therapists have different positions on processes such as the use of verbal reflection and intervention within their work with clients (Hougham, 2017). Some forms of music therapy, for example, create a deliberate connection between reflection and exploration, seeking to link material reflecting the unconscious with verbal communication (Priestley, 1995; John, 1992). Others emphasise the centrality of musical form within the therapeutic encounter (Ansdell, 1995) without the need for verbal exploration. Within approaches emphasising verbal intervention, interpretation can be an important aspect of the way in which meaning emerges from the therapeutic encounter. Writing about the historian’s relationship to documents or descriptions of the past, Lacapra describes the act of interpretation in ways that are useful to consider in relation to the arts therapies: as creative, as ‘a performing art’ (1983: 62). He comments that art is ‘never entirely free . . . the belief in pure interpretation is itself a bid for absolute transcendence that denies both the finite nature of understanding and the need to confront critically what Freud described as “transference”’ (Lacapra, 1983: 63). He goes on to describe historical texts as a network of resistances, and advocates the recognition of interpretation as a dialogue, ‘a good reader is also an attentive listener’ (Lacapra, 1983: 64). Harris argues in a parallel way that ‘a notion of vision, or gazing, or looking, or seeing, as an essentially neutral activity is untenable . . . vision . . . is necessarily subject to social and ideological values and interests’ (Harris, 2001: 151). Notions of pure form, a culturally universal vision, are dismissed as ways of avoiding the importance of understanding vision in the specific context of its relationship to socially and politically specific institutions or situations. Lacapra emphasises the importance of an interest in what does not fit a model or fixed framework for understanding, saying that ‘an openness to what one does not expect to hear from the past may even help to transform the very questions one poses to the past . . . the seeming anomaly



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should be seen as having a special value . . . for it constrains one to doubt overly reductive interpretations and excessively “economical” shortcuts from understanding to action’ (Lacapra, 1983: 64). Though he’s talking about historical texts, I think this approach is useful when considering the idea of interpretation in the arts therapies. He talks about the value of the anomaly from the general. This way of thinking recognises that systems of scientific categorisation might be, at one extreme, inappropriate for the anomalous psyche and for the analysis of artistic expressions: human nature is not best served by such a notion. Human nature’s complexity is not best served in terms of therapy by an approach that categorises in this way. Each individual must be given his or her specific acknowledgement. There are some areas that might usefully be seen in the context of a set of assumptions, but the individual experience of that may be more complex. The individual’s difference may alter the framework applied, and categories or frameworks should be in constant evolution. Each client can affect the development of any framework – the framework can affect the client. It is a dialogue not a monologue – as Lacapra calls it, a ‘dialogical relationship’ (1983: 64). This way of looking at texts, whether they are historical or the expressions in an arts therapy session, is one that is important to the arts therapies. Arts therapists such as Maclagan, for example, echo some of these concerns. He calls imagination, dream and fantasy ‘slippery concepts’ (Maclagan, 1989: 35). He points out that oppositions between outside and inside, real and imaginary, literal and metaphorical are ‘neither necessary nor inevitable: they are, rather, the consequences of a complex set of assumptions about the nature of imagery, and about how “figures” should translate the invisible into visible terms’ (Maclagan, 1989: 35). He argues that a fixed range of concepts is sometimes used as a baseline which images can be read from, or reduced to. He says the danger is that this is reductive and ‘conservative’ (1989: 39). In the following, Maclagan talks about art therapy, but it could be said to be true of all the arts therapies: the art therapist, ‘standing . . . between the therapeutic need to connect and to articulate, and a creative involvement with imagery that is immediate and inarticulate, is bound to have to deal with this tension between the programmatic and the unaccountable’ (1989: 36). He says that the structures of meaning that regulate the ‘traffic’ between ‘inside and outside’ and that effectively license certain forms of expression whilst disqualifying others, have ‘real human consequences; we have an ethical responsibility to re-examine them’. Maclagan develops this to discuss what he calls a tension in art therapy: ‘while the idea of an objective science concerned with the quantifiable aspects of phenomena develops, so the more elusive and qualitative aspects of experience come to be assigned to a private and subjective realm’ (1989: 37). He goes on to say that the pathologising of certain forms of imagery, or the ‘imposition with the full weight of diagnostic authority’, of what he says is an interpretative straitjacket, are ‘the authoritarian effects of a model of imagination that is inherently conservative’ (Maclagan, 1989: 39). So,

186 Agents of transformation   deviation from a ‘figurative norm’ by clients in a psychiatric setting is seen as indicative of disorder, of non-figurative work as being indicative of a withdrawal from reality, or as a refusal to signify in a proper way. Music has also been seen by some as particularly difficult to ‘read’ or interpret. Authors such as Walker (1990: 4) make the point that the sounds of music are ‘vague’ as symbols. It is hard, for example, to isolate a musical sound that is always obviously ‘heroic’ or ‘cowardly’. There is a difficulty in identifying musical elements and showing they represent non-musical objects: ‘musical symbolism is not a simple matter of matching each symbolised object with a different sound so as to form a sort of universal lexicon of musical symbols’ (Walker, 1990: 5). He goes on to add that whereas in art shapes can be made to resemble everyday objects familiar to the observer, and words have more or less fixed meanings, some musical forms can imitate (e.g. a birdcall or a barking dog), but, normally, musical art operates differently from literal reproduction. A composer might choose a sound to represent something, and, by musical convention, that sound may acquire particular evocative or representational powers within a particular context or milieu, but this cannot be guaranteed. He says that the translation of specific musical imagery from one culture to another is impossible. Composers create their own language, and an audience may listen and understand, but musical communication occurs ‘despite the relatively abstract constructions in sound’ (Walker, 1990: 9). Pavlicevic asks whether it is essential to use words to make the music therapy process full, or, ‘were we to leave the musical experience to speak for itself, would it remain unconscious, un-recovered, unaccessed by the client? Could it be limiting a client who was fully verbal – or would it enhance the experience? Might the act of speaking detract from the power of the experience itself?’ (1997: 10). Aiello (1994), speaking about conscious and unconscious reactions to music, says that the response of listeners is dependent on the training or natural psychological inclination of each individual. Some, she argues, rationalise and make conscious their responses to the music, for example. For others the ‘mental tensions’ are experienced mainly as a feeling or affect rather than as conscious cognition. Some arts therapists have written about interpretation within the art form, that the therapist, for example, uses music or mark making or movement to make an interpretation of the material which reflects unconscious content or processes (Odell, 1989). Pavlicevic (1997: 164) asks whether, if the therapist interprets only through music, the musical act can come to a ‘full conscious meaning’ for the client. Sometimes clients ‘know’ something has happened without being able or needing to verbalise it. This knowing is musical in nature, part of the process of making and communicating through music. She asks whether this kind of knowing which is contained within musical expression marks a shift from unconscious to conscious life. Are words needed to ‘explicate’ it? Behind this lies a question – how to find a ‘language’ that fully embraces the complexity of the experience: ‘In music therapy, this language needs to do



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justice to the interactive complexities, to the musical inter-dynamic, and to the unconscious meaning of any feature of these aspects of the therapeutic event, as well as to the whole event’ (Pavlicevic, 1997: 164–5). She, like many other arts therapists, views interpretation as something which can rather than must be used, saying that it is important to guard against interpretation being made just because of theoretical leanings (Pavlicevic, 1997: 165). It can become a creative act, at best involving client and therapist together looking at bringing meaning out of the therapeutic experience. It is important to ask whether verbal interpretation is a reassurance – the therapist needing to assert or to feel that they ‘know what is going on’ – or is a part of the process of counter-transference. This creative mutuality is at the heart of the digging metaphors referred to at the start of this section. The following case example illustrates this. Schaverien, in discussing client Harry’s process in art therapy, rightly speaks of the creation of an image by him – she says that at the time of the emergence of the image there were no words. She says the image itself is ‘eloquent’, and was born from a need to articulate a feeling state, but that the client could not verbalise. He was able ‘to split off and so externalise a state which is likely to have been previously unconscious’ (Schaverien, 1992: 227). She adds that no words could be found by the client, as words could not match the depth which the image touched in ‘the artist’ as viewer of his own creation. Over weeks, and around the production of further images, the original image became familiar, less surprising and Schaverien notes that its content was acknowledged and eventually assimilated – though, she notes, this took time. Birtchnell says that the arts product or work is ‘put together’ in the first place ‘in order to accommodate a number of conflicting themes and, in the finished product, these are ingeniously interlocked’ (1984: 37). Part of the ‘job’ of the arts therapist is to ‘move in’ and disentangle the aesthetic creation to ‘get back to the underlying turmoil’ (Birtchnell, 1984: 37): ‘I see my role as a therapist in assisting the subject to bring . . . conflicts nearer the surface’ (Birtchnell, 1984: 41). Bunt (1997) talks about the ideas of Stern (1985) in relation to the unconscious and meaning. He emphasises Stern’s idea that communication concerns ‘affect attunement’ (Bunt, 1997: 255). Two communicators are trying to understand each other’s emotional state, and once this has occurred then communication is able to happen in several modalities. This could be said to be a part of the way the relationship between arts therapist and client can form – the attunement of trying to understand followed by different layers of communication within the arts therapy session. This sums up key elements of what both Birtchnell and Schaverien describe – the ways in which the relationship within the session, between client, art making and product, and therapist, allows complexities of communication and relationship to become meaningful. These allow conscious and unconscious to connect in particular ways – to become, in Schaverien’s sense of the word, eloquent. Such connection can be seen in Chapter 17’s

188 Agents of transformation   analyses of Case Study, including those of Leclerc and client ‘Genevieve’, or Schaverien and ‘Harry’ (pages 317–18).

Focus on Research: art therapy Interview with art psychotherapist Josée Leclerc This interview is based on the research ‘The Unconscious as Paradox: Impact on the Epistemological Stance of the Art Psychotherapist’ (Leclerc, 2006). Many of these themes are brought together in Josée Leclerc’s work. This illuminates the client–therapist relationship, image making and the ‘potential space’, and considers attunement along with a presentation of processes such as ‘the emergence of non-conscious implicit memories’ and the ‘sensorial, perceptual and emotional’ nature of the arts. Her study explores how this paradigm positions practice as involving ‘a form of visual thinking which is instrumental in acquiring knowledge about unconscious psychic transmissions occurring between patient, image and art therapist’ (2006: 130). JONES:

In the article you ask the question: ‘How does one know that something pertaining to the realm of the unconscious has manifested itself, for instance, in an art therapy session?’ (2006: 130). You are an artist, an art therapist and a psychoanalytic psychotherapist. How would you say the differences and parallels between these three domains contribute to your understanding of the nature of the unconscious in your engagement with art therapy? LECLERC: Over my years of clinical practice, I feel that these three domains have become progressively integrated; so much so that it would be diffcult for me to identify the impact each one separately has on my ‘sensitivity’ to the unfolding of unconscious manifestation and my capability to work (or ‘play’) with it in order to assist clients on the road toward self-awareness. While recognising that engaging in my own art practice is different than conducting art therapy and psychotherapy sessions with clients, there are, in my view, common factors within these practices. To name but a few, all three domains require a deep engagement in a process that cannot be entirely planned or controlled, a process for which it is not known where it will lead. Furthermore, a mental or psychical disposition is necessary that is, to be disposed to being exposed to the unexpected and the unknown or better still, to the ‘unthought known’, as Christopher Bollas would say. While a client in art therapy may intend to represent something visually, such as dream or an issue faced during the week, in most cases, forms or lines will appear that were not intended; colours will be added that were not sought; accidents or ‘slips’ of the crayon or the paint brush will occur. The same phenomena may occur in my art practice. It’s as if the creative process has a ‘mind of its own’ and in some ways,



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it does. It opens up that third area of experience so dear to Winnicott, a ‘potential space’ which is neither subjective or objective, inner or outer but both. A similar process happens in psychoanalytic psychotherapy. For example, there may often be marked differences between what a client consciously wishes to say and what ends up being communicated, perhaps due to a slip of the tongue or a change in the emotional tone it was expressed. In all three domains, the deep immersion into such experiential processes fosters a temporary loosening of ego control and boundaries, while defences lessen, potentially allowing for unconscious material to emerge. In both my art practice and my clinical practice, I need to allow the process to unfold. I must permit it to go where it needs to go. I must surrender to it. Images and thoughts enter my psyche, feelings arise. I welcome them (most of the time . . .), nurture them, let them sit and resonate within me, direct my gaze at what they may symbolise, listen to the latent messages they may hold, all of which, in my clinical practice, is based on taking into consideration the unicity of the client’s outer and inner worlds, psychic reality and mental functioning, as well as the intersubjectivity of the therapeutic relationship. A state of openness is therefore required, permeable to the flow of unconscious communication from client to therapist. I see the role of art psychotherapist as first being a witness to these occurrences; then a container, taking them in and holding them for the client; and then a translator, rendering them to the client in a ‘digestible form’ to use Bion’s meaningful metaphor, whether something is verbally expressed or not. JONES: You talk about the role of ‘reverie’ and the art therapist’s access to ‘implicit visual memory’. Would you say this combination is something that is unique to the role of the art therapist and client, compared to other forms of psychotherapy? LECLERC: Reverie was an important notion from the start of psychoanalysis and still is today. Freud’s use of the couch was intended to facilitate a relaxation of the ego control and to foster associative thoughts in the patient, allowing unconscious or repressed memory to emerge. The analyst’s foating attention to the patient’s discourse and associations can also be seen as form of reverie in which inner thoughts, feelings and mental images surface from within the analyst. There is a contemplative quality to reverie, which is not without similarities to meditation. Likewise, reverie is a potential experience of the art therapist and client. When the client engages in the creative process and the art therapist functions as a witness, this also induces a lessening of the ego control and fosters implicit forms of communication. Furthermore, the triadic relationship, a phenomenon specifc to art therapy, includes the image as a third member (I use the word image in a generic sense). Accordingly, the materiality of the image plays an essential role. Unlike words, which are more evanescent, once created by the client, the visual art image serves as a concreate support upon

190 Agents of transformation   which both the gaze of client and art therapist can ‘land’. While gazing at, or into, the image, an internal dialogue takes place for both protagonists of the art therapeutic relationship. Associations occur in the form of mental images, thoughts and feelings. All these occurrences can be seen today as implicit communication. The power of art to elicit strong aesthetic emotions cannot be denied. Who hasn’t, for example, been moved to tears in front of a work of art hung on the wall of a museum or even by a client’s art image? This is what I call, in French, the atteinte of the image, a notion akin to what Judith Butler designates by the reach of the image. Art is a non-verbal language; it is sensorial, perceptual and emotional in nature. And as such, it is a powerful form of implicit communication. Verbal language, on the other hand, is a form of explicit communication. The art image in art therapy, or more its presentation effects, are thus liable to serve as a gateway to the emergence of non-conscious implicit memories. JONES: You argue that the art therapist ‘is both the subject and object of knowledge’ (2006: 133), connecting this to what you describe as being ‘the object of unconscious transmissions’ and ‘the subject of deep intersubjective experiences’. Could you say what is especially important about the role of supervision for the art therapist concerning these relationships? LECLERC: You raise a very important question. I am thankful that you invited me to refect on the implications of the art therapist as subject and object of knowledge as I see it from an art psychotherapy perspective. But frst, I would like to acknowledge that there are many approaches in art therapy and different views with regards to the role and functions of the art therapist. I would add that ethics requires art therapists to adapt their approach to the specifc needs of the client. That being said, I don’t believe it is possible or ethical to work from an in-depth model of intervention without proper training and without having gone through this process personally as a client, meaning without having had a felt experience of this process and have ‘survived it’, as mentioned in my article. In other words, I stress the importance of having experienced the challenges of the psychotherapeutic process, the vulnerability of being in the client’s position, the rise of powerful emotions, including transference, and the helplessness felt when defences lessen and awareness of unconscious material begins to arise. I also emphasise the value of having experienced the deep empathy, attunement, unconditional acceptance and holding from the therapist. And finally, I must underline the profound gratitude felt by both client and therapist once termination comes, and the feeling that the experience, although always incomplete, has been good-enough. In this regard, supervision is indeed essential, especially for the beginning art therapist, and periodically yet regularly for the experienced art



  The sensuous encounter 191 therapist. The Concordia University Master’s programme in Art Therapy has a strong psychodynamic approach, as well as providing a base in other theoretical models. Student-interns learn the core principles of this model of intervention and acquire clinical skills which are put into practice in their internships, especially so in their second year of training. Art therapy professors thus strongly believe in the importance of providing a fair amount of in-depth supervision, which is offered to students in both group and individual sessions. In addition, student-interns receive supervision from professionals at their internship sites. It is very rewarding to witness the professional and personal growth of our dedicated students. I am often in awe at their courage and openness to self-exploration.

Conclusion In arts therapy practice operating within a framework that acknowledges the unconscious, the relationship between internal and external is at the core of change. The basic notion is that the client’s internal unconscious world, containing repressed material, becomes connected with the arts products, the materials used, and the processes within the session. This can involve the making of music, images, enactments or dance, the relationship with the therapist, and with other clients, if the therapy involves a group. The arts therapies’ engagement with the unconscious is seen as dynamic: linking art making, the process of the relationship with the therapist or with others, as a route to uncover, to create contact where there is disconnection, and to allow healing to occur with material that is buried or split off. Some arts therapists, as we have seen, when discussing clinical practice, use topographic imagery. This relationship is one where the unconscious is seen as a domain, a repository or as a resource. The arts therapist and client together engage in an act of archaeology within the therapy – the excavation can lead to the emergence of material through image, movement, enactment or sound. The relationship between therapist and client is also seen to be reflective of patterns, issues, internally held aspects of identity and relationships from outside the session through transference. The presence of making and the made artefact or product is also seen as an important aspect of reflecting and working with unconscious material. The therapist and client work with meaning and how the emergent meaning alters the client. For some clients the change from holding something within to finding expression in an artistic form is a key aspect of therapeutic change. Another aspect is seen to be the relationship with the therapist as this develops – the client ‘working through’ issues. Another facet is the act of intervention from the therapist – through interpretation or engagement with the clients’ work. The arts therapy space is seen as an opportunity for access, expression, exploration and change. The arts form and product is a means of contact, becoming both a container and transformative agent.

192 Agents of transformation   These are the ways the unconscious is viewed, and positioned as an agent of change. The unconscious is seen by most arts therapists in ways that reflect both the analytic and the artistic traditions: revolutions in the way the psyche and self are understood. Some work reflects ideas of the unconscious as a place which is the origin of inspiration and creativity. The processes of making can be connected to the unconscious as a way of assisting healing or reparative processes. The unconscious here is a source of creativity, and of reflecting ways in which therapist and client can work together to achieve an integration of splits or difficulties. The unconscious is also considered a place of suppressed memories, experiences or unacceptable aspects of identity. The arts therapies enable particular relationships to occur, where the artistic process within a therapeutic framework and relationship enhances and provides particular forms of reflection and communication with the material which is seen as buried or suppressed. Once expression and communication are made, then the potentials of the therapeutic space and encounter can be connected to the buried or cut-off material. Robbins describes the process in this way: All too often . . . the psychological implications of one’s art are unconscious or dissociated from self-expression. In art therapy, on the other hand, we are constantly working to make aesthetic expression a complement to self-expression in one’s relationship with others. In that process, the art therapist works with an individual’s character defences and slowly helps him to digest emotionally the full impact of the symbolic communications. (Robbins, 1987: 23) The emphasis is upon the potentials that the arts therapies bring to their contact and dialogue with the unconscious. The unconscious is encountered through the physical expression, relationships and artistic processes within the arts therapies. They evoke and enable the encounter of material in particular ways; as Leclerc acknowledges in her interview, the arts are ‘sensorial, perceptual and emotional in nature’. The relationship is not one-way – it is not only that the unconscious material is given expression and that consciousness enables change. There is a dialectical, alive relationship that is established between expression and engagement in the arts therapy space and the clients’ unconscious. The unconscious is not closed; it is seen to be a living, changing element, brought into dialogue through the unique opportunities the arts therapies make possible. It must be remembered, as the start of this chapter acknowledged, that though ideas connecting the arts, the unconscious and change are important in the arts therapies, not all practice is connected to these concepts. The therapy space, the relationship between the arts, the arts therapist and the client are seen very differently by some arts therapists with other orientations. How, then, does the therapeutic orientation of the arts



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therapy practice affect the opportunities for the client? Case and Dalley say that the various perspectives concerning orientation will ‘place different emphases in terms of understanding this art process’ (2014: 53). They contrast, for example, those emphasising the healing qualities of the arts form with more psychoanalytically influenced art therapists. Is this the case? Are there such differences for clients? The next chapter will look further at these questions.

thirteen

Playing, development and change Introduction: definitions and theories of play One morning, during breaktime, some English schoolchildren were at play whilst work was being undertaken on an adjacent building. A man working on the lights of this building fell to his death during this break. The incident occurred only a few feet away from where a dozen children were playing. By chance, a project happened to be in progress at the school. This involved recording and analysing the ways the children played. The recordings, based on 3–6-year-olds, began to show patterns and themes in the play. For months afterwards the children’s play reflected the incident. Children played falling and jumping, referring to falling on their head, asking questions such as ‘Where’s the body? We have to go to hospital and take the body’, giving instructions such as, ‘Fall like that man’. In their play they used details of the accident such as bleeding eyes, nose and mouth, wearing hard hats and being in hospital. A variety of dangerous situations concerning falling and death were created. A cat was shot dead and fell out of a tree, for example, and a group of boys replayed an incident for many months in which one of them fell and died, was taken to hospital and examined with stethoscopes (Brown et al., 1971: 29). What have such observations to do with the arts therapies? How can such playing be connected to the therapeutic potentials of the arts? Developments in understanding play, made through observations such as this, have contributed to the arts therapies in many ways. The last chapter emphasised how notions of the unconscious have been influential in considering why the arts therapies are effective. Another important influence in the historical emergence of the arts therapies, and in their ways of working, has been children’s play. Feezer draws our attention to the modern plurality of understandings and definitions within an overall frame that recognises ‘the pervasive influence and importance of play in human life’ (2013: 14). This chapter will explore how radical shifts in understandings of play have been important to theories of change in the arts therapies, and in developing approaches to practice. It’s no coincidence that a number of key figures involved in creating the early connections between the arts and therapy worked with children. 194



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Some have argued that their inspiration for seeing how the arts and therapy could connect lay in their observations and experiences of the way healing occurred for children in and through their play. Peter Slade, for example, one of the first to use the term dramatherapy in 1930s England, says: I wasn’t happy at school. We would go up into the Downs and dance and improvise. We’d improvise about the masters we hated. The stage, the formal stage was never enough for me . . . looking at children gave me the feeling that . . . children had a drama of their own . . . You’re allowed to be like a child again and you can spit out what you want. (Slade, in Jones, 2007: 83–4) He has said that his own experiences of playing, combined with his work in schools with play and drama, enabled him to begin to realise the therapeutic possibilities of the arts. He began to see the potentials of play and drama to reflect, contain and transform experiences for those involved (Slade, 1995). As we will see, such insights into play occur in many places, and from different perspectives. In the Netherlands, for example, Wils (1973) produced his influential book Bij wijze van spelen (By Means of Playing), which was formative in the development of thinking and practice of the arts as a potential for therapy in that country. Key to much recent thinking and research are the ways in which diversity of culture or processes such as social exclusion affect play (Howie et al. 2013). Authors such as Ogawa and Tinkai (2017) or Napitupulu (2017) have looked at the processes, languages and relationships of play in Japanese and Indonesian contexts, whilst Ogunyemi and Ragpot (2015) have explored how factors such as poverty, resourcing and cultural attitude connect to play in South Africa and Nigeria. These perspectives help highlight some of the complexities and opportunities that examining play offers to our developing understanding of the arts therapies. Some arts therapists have proposed that play and creativity in the arts have many common properties. The area of play, especially in relationship to object play, is seen in terms of the origin of creativity in human development. Arts therapists such as Malchiodi (2012) draw parallels, arguing that inherent in playing, and in creativity involving the arts, are potentials for healing. It is as if children, within their play, spontaneously deal with a number of difficulties and developmental opportunities or challenges they are encountering. In many cultures play is the domain of the child and some argue that the opportunities of aspects of play can be lost to individuals as they age (Jennings, 2010). Another facet of playing within the arts therapies is that it can offer the benefits of play and a ‘playful state’ to adults. However, this is a complex process for many adults who may view playfulness as not part of their domain, but that of the child, or as not being age appropriate. Some argue that the arts therapies can access for children and adults alike the inherent potentials of play. Malchiodi,

196 Agents of transformation   for example, says that ‘in clinical work . . . art and play have always been closely intertwined . . . [sharing] . . . a common bond through . . . their healing qualities of creativity, spontaneous expression, make-believe, and non-threatening, developmentally appropriate communication’ (1999a: 22). Blatner and Blatner refer to the connections between play and the therapeutic space in psychodrama as ‘a fluid dimension’, where reality becomes more malleable and hence safer, enabling ‘creative risk taking’ (1988: 78). As this chapter will show, looked at in this way, the arts therapist is creating a space and an opportunity for this playful state to emerge. Within this they are using their relationship with the client to try to encourage and support inherent healing processes within playing and the arts to be realised to their fullest potential. Other ways of looking at play within the arts therapies concern the notion that it enables development and maturation (Snow and D’Amico, 2009). Such claims build on the work of analysts, psychologists, educationalists and play specialists who argue that play is vital to psychological, emotional and social development. Here the arts therapy space becomes a place for barriers or problems with stages of development to be worked with. This might involve using arts processes and the relationship with the arts therapist to assist a client with an aspect of their emotional, psychological or social development. Other work aims to revisit stages of development that are problematic, and to renegotiate or re-work them. Here the language of the arts is seen to reflect the possibilities that play offers, or the relationship with the therapist is seen as one that can support or work through the developmental process. This chapter will look at examples of such perspectives on play and the arts therapies. Questions arise from these ideas and possibilities: what is play? Is play something that ends at the close of childhood? Are ideas about the healing aspects of play grounded in evidence? How do such areas relate to the arts therapies? This chapter will explore these questions in order to examine how play and the arts therapies relate to each other.

What is play? Psychologists, psychoanalysts, biologists, anthropologists, economists and educationalists have all re-examined play in ways that have completely changed our perceptions of what play is, and how it relates to living. The arts therapies create dialogue with a number of these, particularly ideas and discoveries concerning play and development, and psychoanalytic theories of play. In many situations children are seen to play spontaneously: that is, they will often provide their own impetus and involvement in play without the encouragement of adults. Many researchers and practitioners comment on the satisfaction and absorption that play often seems to provide. Courtney describes this very well: ‘Play is something that all children want and need to do: their motivation is so strong that, at home, they can often be so



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absorbed in their play that they forget to come for meals’ (1988: 59). Recent research has begun to explore what those primarily involved, the children themselves, perceive play to be, rather than adults. In Barnett’s (2013) US study, children aged 8–11, identified as Caucasian, African American, Asian American and Hispanic, were invited to define what play meant to them. The research reveals that the children emphasised it as offering fun and the importance of being able to play in the way they wanted to, to be alone or with others, of being active and having time away from things they were obliged to do (such as school). Activities and processes described as ‘play’ vary enormously, and change as the individual develops and grows. These include movement: from a baby playing with their own toes to crawling to throwing, catching, running; sound making; talking; games; fantasy activities and playing with objects. Processes often described as ‘play’ also vary enormously from imitative play, where the focus is on copying and repeating, through to areas such as constructive play and pretend play, where the emphasis is upon combining objects and materials or creating make-believe situations (Andersen-Warren and Grainger, 2000: 52–3). The understanding of how and why play occurs varies widely. The past century has seen enormous changes in the way play is understood. Rather than being seen as incidental, it is now considered to be central to areas such as maturation, and a child’s understanding of him or herself and the world they encounter. It is understood as an arena reflecting emotional and psychological concerns, where a child’s play is a means of expressing feelings, dealing with difficulties and assimilating experiences. Many, such as psychoanalyst Winnicott, have connected play to the arts; as Case and Dalley say, ‘cultural experience begins with creative living first manifested in play’ (2014: 88). Such changes have enabled the area of play to have an important role in the emergence and development of the arts therapies. Play does not happen in a sealed vacuum, and its languages and processes are not the same for all people. A number of factors can affect play. Research has shown that play can vary between different cultures, for example. Some researchers have looked at the effects of cultural and socio-economic factors on the different ways in which play occurs. Some look at the parallels in play and play processes between cultures. Others look at the ways in which specific processes are inhibited due to socio-economic or cultural factors. Bowlby has commented that in some institutional settings play may be limited as individual activity might be seen as a nuisance, or toys may be lacking, or positive encouraging attention is absent (1985: 64). Subsequent researchers have said, for example, that when children are seen as an ‘economic asset’ and work, then play is reduced. Singer et al. (2009) interviewed 2,400 mothers in sixteen countries about their children’s play, describing the diversity of contexts as covering ‘developed’, ‘newly industrialised’ and ‘developing’ countries including the USA, Argentina, France, Pakistan, Morocco, South Africa and Vietnam. Mothers in the different countries revealed parallel and divergent concerns and perceptions ‘about their own attitudes, beliefs,

198 Agents of transformation   and perceptions about their children’s play, and their concerns about their children’s well-being and futures’ (2009: 304): •

•

•

•

•

Most mothers globally were concerned about the relationship between play and a child’s general health. An average of 42 per cent of mothers in the sample reported that they worry that their children do not play enough to be healthy. Nearly half (47 per cent) of mothers globally worried that their children spend too little time playing outside. Mothers in developing (76 per cent) and newly industrialised countries (64 per cent) worried about safety more frequently than mothers in developed countries (43 per cent). 77 per cent of mothers wished their children had more opportunities to interact with other children. In addition, 87 per cent of all mothers wished for more time to play and interact with their children, while in developing countries, 94 per cent of mothers expressed this desire. Mothers globally (67 per cent) worried that without enough social play, their children’s generation will not fully learn how to form relationships. 66 per cent of mothers agreed that without enough time for play, their children were unhappy. Mothers in Turkey and Africa were significantly more likely to concur with the sentiment compared to all of the other regions. When examining differences among urban, suburban and rural mothers, the research found that a higher percentage of mothers from cities wished that they could spend more time interacting and playing with their children. More urban mothers also wished that their children had more play time with other children. (Singer et al., 2009: 303–5)

Many authors refer to research indicating the negative impact on play of changes in urban life and the way children have access to opportunities for playing. Factors such as parental fear of children’s safety from dangers of traffic and violent crime (Rosenbaum, 1993) are cited. Others indicate that children from minority ethnic groups may be inhibited from playing outside the home by fears of racial harassment (Robb, 2001: 23). Related to Singer et al.’s findings, researchers in different countries have identified the interaction of factors such as poverty, health, the training and attitudes of service providers and family conditions. In their review of play and young children’s situation in Nigeria and South Africa, for example, Ogunyemi and Ragpot conclude that: Integrated in the South African constitution is the Bill of Rights, which makes provision for the socio-economic rights of children. Although these include a right to basic education and protection from neglect, abuse and exploitation, the evidence suggests that ‘South Africa still has a long way to go to effect quality of life for the majority of



  Playing, development and change 199 her children’ (Atmore et al. 2012: 1). Two inter-related factors in this respect are the issue of poverty and the effect of HIV-AIDS child-headed homes. (Ogunyemi and Ragpot, 2015: 9)

They note that the situation for children and play in both countries is ‘made worse’ by mass poverty and disease, which they connect in South Africa to the long Apartheid regime (which only ended in 1994) and in Nigeria to ‘years of misrule and mismanagement of the country’s wealth’. Their argument is that there is a need to combat poverty, inequality and exclusion, build and act upon child-centred policies, to promote information about the value of play and to train professionals working with play about the values of play in children’s lives. Farley’s (2005) review in the USA found that whilst most paediatricians and child-development experts agreed that unstructured activities and play were important to children’s health and socialisation, the emphasis on academic-test performance has resulted in severe cutbacks in children’s freeplay time and in recess during the school day. Robb (2001) also points to research into play and cultural changes in areas such as mass media. The impact of computers and television, for example, meaning that there is less social interaction in children’s play. However, some have indicated that this area of playing still impacts on emotional development. Granic et al. (2014) argue that virtual games may have a positive effect on cognitive, motivational, emotional and social benefits, asserting, for example, that playing video games may foster realworld psychosocial benefits. These perspectives all show the different ways in which play is understood to be important to both a child’s, or client’s, internal world, and within the context in which they live their lives. They also show the ways in which play in children’s lives can be affected by a number of interconnected factors, from poverty to the pressures of education, from racial prejudice to an absence of child-centred policy. Many theories have begun to emphasise play within the child’s life situation rather than focusing primarily on the internal processes of the child. Vygotsky’s (1967) theoretical work, for example, has been influential in addressing the ways in which play is seen to relate to social and emotional needs. Play, he proposes, frees the child from the immediate constraints of a situation by creating a ‘mental arena’. Play often involves the creation of an imaginary situation. This is seen as part of a child developing a social framework. The child develops internal mental representations of how objects, for example, can be manipulated. Internal mental structures are constructed and developed from the child’s use of signs. Speech becomes a powerful factor in controlling and using objects as tools and in developing understanding. Playing involves the child’s creating a commentary or inner monologue about what is happening. This becomes a kind of inner speech that allows the child to monitor what he or she is doing, and forms the basis of communication. These factors combine to create a mental framework for the child in the formation of their imagination, and in relating to and understanding the world they are within.

200 Agents of transformation   These, then, are some of the ways in which views on play have radically changed. How are these relevant to the arts therapies?

The arts therapies and play A central idea within the arts therapies is that play and the arts have important parallels. As we saw, some of the early pioneers held this opinion. From one point of view early play develops into creativity and art making, from another playing and art making share many processes. As we will see, the discoveries made in each area can help us see more clearly how, and why, change happens. Case and Dalley (2014), for example, have commented on how people working with play and therapy, such as Winnicott, have given names to concepts of importance to art therapy: these include the child’s frst use of symbol, the idea of the transitional object, the importance of fantasy and of play’s relationship to cultural experience. This section shows how some of the discoveries and ways of working in areas such as psychoanalysis, play therapy and in developmental work with play relate to the arts therapies. It then goes on to look more directly at areas of arts therapies practice. Within psychoanalysis, practitioners such as Klein (1932) and Anna Freud (1965) used spontaneous play in a way that is analogous to free association. One of the key notions here is of play involving an expression of underlying psychological conflicts and complexes. This tradition can be seen in play therapist Axline’s work with her client ‘Dibs’. Here is a sample of the play Dibs engaged in:

Therapist’s account Dibs buried three toy soldiers in the sand. ‘This makes them unhappy,’ he said. ‘They cannot see. They cannot hear. They cannot breathe,’ he explained. ‘Dibs dig them out of there,’ he ordered himself . . . He held out one toward me. ‘This is Papa,’ he said identifying it. ‘Oh? That one is Papa, is it?’ I remarked casually. ‘Yes,’ he replied. He stood it on the floor in front of him, shut his fist, knocked it over, stood it up, knocked it over with his fist. He repeated this several times. Then he looked at me. ‘Four more minutes left?’ he asked. (Axline, 1964: 67)

This is a moment from a long process of therapeutic work. Over time, Axline and Dibs have created a space where Dibs can play within the safe boundaries of a therapeutic space and a therapeutic relationship. Axline accompanies him in his playing. As the excerpt illustrates, Dibs can play



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in front of her, and can comment, discuss and think about his play with her. The idea here is that play is a natural language for the child, and that the process of playing within the space that they have created can hold therapeutic opportunities for Dibs. The language of play can enable Dibs to express, explore and work with themes and situations that are problematic. Things that might be hard to discuss with words alone can be reflected and expressed indirectly through the play images of soldiers, sand and breathing. It can also provide images that may help Dibs feel and assimilate things about his life. For example, the play with soldiers and sand may help by enabling him to create aspects of his relationship with his father. The presence of the play space, the relationship with Axline and the available fantasy images help him to explore things about himself and his father. In addition, he can communicate these things to someone else who is accompanying him in his playing. Hayes sums up an aspect of this approach to play in his analysis of Axline’s therapeutic work with Dibs, saying that the child’s behaviour as he plays, ‘not only allowed the therapist to gain insight into the child’s problems, but also allowed the child to express the hidden anger and distress which he could not express at home’ (Hayes, 1994: 745). Grainger talks about aspects of the ‘flow’ and the dynamic of the ‘as if’ in play and the arts therapies (Andersen-Warren, and Grainger, 2000; Duggan and Grainger, 1997; Grainger, 2014). He variously describes ‘flow’ and ‘as if’ as lying at the heart of human relationship (Duggan and Grainger, 1997: 6) and something that ‘as human beings, we need most of all’ (Grainger, 2006: 122). This is approached by him through the door of ‘the language of psychology’ where the act of ‘“as if” stands for the way of thinking and behaving whereby I imagine that I am you and you are me’ (Duggan and Grainger, 1997: 6). This brings the act of psychological imagining into relation with the arts, personal experience and change. The arts bring in sensory experience and presence through the visible, tactile, aural and olfactory (1997: 8). These processes are connected by them to Goffman’s social theatre and Winnicott’s object relations theory, becoming connections that draw the ‘as if’, not only into sensory experience and presence, but to the creating of the interaction of self hood and our encounter with ‘separateness’ (1997: 8) and what Duggan and Grainger call ‘the growth of the capacity for between-ness in human beings’ (1997: 9). This growing sparking of ideas, concepts and potentials connect with play and, for example, dramatherapy’s position that in play is ‘real and not real at the same time, and that in a playful state pleasure can be brought to experience and consequence is reconfigured: we don’t feel so exposed; because the experience of meeting and sharing that it provides is an authentic one, it gives us confidence and makes us feel real ’(1997: 12). This is seen as ‘a major theme’ and described as ‘playing with danger and safety’ as it is ‘fundamental to the way that drama and theater work’ (1997: 12). The particular use of interdisciplinarity in this area of Grainger’s work operates to offer both explanation and insight. He refers to such diverse perceptions of play as helping to ‘shed more light on the factors within the dramatherapy context which are healing’ (Grainger, 2006: 19). Such dialogue, he concludes, helps

202 Agents of transformation   to reveal that ‘dramatherapy’s effectiveness is directly proportional to our willingness and ability’ to be involved in a ‘shared world’ of ‘make believe’ (2006: 19). This occurs in a way that can ‘affect our experience of ordinary life’: he refers to the ‘“as if” principle . . . this imaginative incursion into someone else’s experience is a source of personal health and psychological wholeness’ (Grainger, 2006: 19). The relationship of play to maturation has also been important within the arts therapies. Play is seen as a key factor in a variety of areas: cognitive, intellectual and social maturation. Piaget (1962), for example, argued that children pass through stages of cognitive development – sensorimotor, preoperational, concrete operational and formal operational stages. The types of play engaged in are different during these cognitive stages. For example, in the sensorimotor stage the child engages in mastery play. This is seen to allow the child to gain control of their environment, learning to control muscles and actions. In the pre-operational stage, the child is more likely to engage in symbolic play involving fantasy and make-believe: this is seen to reflect the developmental issues the child is engaged with – creating an understanding of their world. Sheridan sums up this developmental approach to play succinctly: Each aspect of development is intricately linked and if one aspect is hampered or neglected in some way a child will fail to reach her full potential . . . Play is as important for a child’s developmental needs as good nutrition, warmth and protection. It provides opportunities to improve gross and fine motor skills and maintain physical health. It helps to develop imagination and creativity, provides a context in which to practise social skills, acts as an outlet for emotional expression and provides opportunities to understand value systems. (Sheridan, 1999: 6) A number of approaches to understanding and working with such notions of development are used within the arts therapies. The idea of normative development is one that has created debate and challenge, though. Some, for example, have challenged the idea that underlies some of the developmental models described above. They criticise the notion of stages that are used to define ‘normal’ progression, and advocate the idea of different routes through development that reflect difference and idiosyncrasy. Gewirtz and Cribb (2009), for example, have criticised traditional notions of developmental psychology from a feminist perspective, arguing that it enforces a focus on the individual from a reductive perspective, without looking at contextual and structural factors, such as gender, that relate to how children are seen in terms of their play and development. Read Johnson (1998) has reviewed the influence of aspects of Piaget’s work on arts therapists’ practice, for example. He particularly identifies the application of Piaget’s ideas of accommodation and assimilation in



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interpersonal relationships. Baker echoes this in summarising aspects of play relating to the child’s negotiating a relationship between themselves and the world they encounter: around the age of four co-operative play emerges clearly, and we notice children in . . . corresponding long periods of time in play . . . these children are deliberately playing at life. In group or co-operative play, children often consciously play out events they have witnessed or heard in order to master the puzzling or frightening new experiences, and subsequently learn how to come to terms with them, to cope with new sensations, new ideas, new people and things . . . (Baker, 1981: 223) This aspect of play – of children accommodating and assimilating the connections of things they see or are involved in – relates to the play described at the opening of this chapter. In replaying the accident, or in playing with themes relating to their encounter with the event, play can be seen to offer the children assimilation of what had happened through their re-encountering it as play. In their games they worked with each other and with shared images and processes. Similarly, as we saw, the play of Dibs with Axline showed the child discovering connections between the soldiers and sand and his father. Malchiodi describes this process within art therapy with an 8-year-old boy on a paediatric burns unit. He continually repeated a drawing of his house where he was burnt in a fre: My interaction with the boy during his hospitalization involved helping him develop themes of safety through play and resolution of his fears about being in his house for fear of being burned again. Repetitions of art or play are an important part of the curative process of medical art therapy, in that it allows the child to gain a symbolic power over the trauma through repeating an image and with the therapist’s help, eventually mastering the traumatic event. (Malchiodi, 1999a: 179) Garvey (1984) has described the importance of children forming relationships and communicating key aspects of their experience. She refers to research in play undertaken by Gottman and Parkhurst (1977). Their study considered the ways in which play developed within friendships. One strand was described by them as ‘shared deviance’, which involved planning naughty or forbidden actions. One, for example, involved a plot to poison the mother of one of the children by hiding pretend lethal beans in food she was cooking. The mother was not poisoned, but Gottman and Parkhurst see this activity in terms of consolidating intimacy. Garvey adds that such fantasy play creates ‘shared understandings and mutually constructed history of their play and life together [this] permits the communicative work

204 Agents of transformation   of play to move beyond the essential organisational negotiations into the exploration of both personal images and feelings and new experiences they want to share and extend’ (Garvey, 1984: 172). This emphasis on the creation of fantasy images that have a capacity to hold personal meaning and relationship is important in thinking about the processes at work within the arts therapies. There is an analogy here between the images that emerge in children’s play and the creation of imagery within some arts therapy work. Murphy, for example, has said that the arts and play have the spontaneous externalisation of images in common; these ‘enable children to face anxiety-provoking situations metaphorically’ (2001: 5). She says that children often move from what she calls ‘one medium to another’, in relation to image making, from art to play. In reality, I think that many arts therapists from different disciplines would see play and the arts as closely interrelated in this area, as we will see. These crucial processes do not finish when the child becomes an adult. Many argue that play is not something that is confined to children and childhood. Indeed, the presence of play as an active force within the arts therapies with all groups and individuals supports this notion: The classic authors in developmental psychology . . . Piaget or Freud, portray early fantasy and early pretend play as something that is immature and will be outgrown. Piaget describes this narcissistic self absorption in unrealistic fantasies and he talks about pretend play as a form of associative thinking that will eventually disappear as the child becomes more objective. But if you look at children with autism and see how restricted their imagination is, you are forced to the conclusion that imagination is probably something that we can’t do without, and not something that we need to overcome. (Harris, 2001: 2) This led Harris to explore the idea of continuities from children’s pretend play into adulthood. The arts therapies, as we will see, use play in work with adults as well as with children, and offer a rationale for one way of considering the need for a continuity of play outside childhood. In what ways, then, do the arts therapies specifically relate to play and playing? The next sections look at key areas in detail: the playful space, playfulness, the play shift and a developmental perspective. Here we will see how play and the arts therapies relate, not only in terms of theory, but also in the ways practice is undertaken.

The play space The creation of a play space involves an area that is both set apart yet connected to the everyday life of the client. As described by theorists referred



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to earlier in this chapter, this space has specifc rules and ways of being. Within the arts therapies Winnicott’s notion of the transitional object and the related idea of potential space have been important. Winnicott (1974) described play as a ‘potential space’, essential for the infant to establish relationships between their inner world and outer experience. This space is one in which a negotiation between an individual’s identity and the surrounding world takes place. Read Johnson (1999) has said that the concept of ‘transitional space’ permeates the literature of the arts therapies. He argues, however, that Winnicott did not make use of the term transitional space, and that his phrase ‘potential space’ focused on interpersonal interaction. For arts therapists, Read Johnson argues, the main use of this concept has concerned the spatial aspects of its meaning: ‘The notion of transitional space provides an excellent description of the environment that is re-created in the creative arts therapy session: that is, an aesthetic, imaginal, metaphoric space in which inside and outside, self and other, are mixed’ (Read Johnson, 1999: 146). It is part of creating and negotiating meaning and relationship: ‘The areas of communication, the manipulation, mastery and coming to terms with reality and the notion of testing and assimilating which typifes the state of playing are all relevant to the way play manifests itself in therapy’ (Jones, 2007: 173). This space within the arts therapies often echoes Griffing’s (1983) four areas of preparation for play: a distinct time; a safe space; appropriate materials; and preparatory activities. Axline, to return briefly to her work with Dibs, defines the therapy space in a way that brings together play space and therapeutic space, also indicating the importance of time and safety. Dibs initiates a discussion of the boundaries by taking the card Axline puts on the therapy room door to ask people not to enter:

Therapist’s account Suddenly he pulled his feet out of the sand, stood up, jumped out of the sandbox, and opened the playroom door. He reached up, took the card out of the holder, came back into the room, closed the door, thrust the card at me. ‘What is therapy?’ he asked me. I was astonished. ‘Therapy?’ I said, ‘Well, let me think for a minute.’ Why had he asked this question, I wondered. What explanation would make a sensible reply? ‘I would say that it means a chance to come here and play and talk just about any way you want to,’ I said. ‘It’s a time when you can be the way you want to be. A time you can use any way you want to use it. A time when you can be you.’ That was the best explanation I could come up with then. He took the card out of my hand. He turned it to the other side.

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‘I know what this means,’ he said. “Do not disturb” means everybody please let them alone. Don’t bother them . . . Just let them both be. This side means they are being. And this side says you let them both be!’ (Axline, 1964: 105)

A part of this interaction shows us what Dibs seems to be saying about the space, that they are ‘let . . . alone’ and that he is ‘being’ with himself and Axline. It’s also interesting to see how Axline answers his question about the definition of therapy by starting three of her four sentences with ‘time’. This might be seen as an unconscious reflection on her part of the importance of this aspect of boundaries and the creation of a safe space: time. She also stresses the importance of Dibs’s being able to do what he wants, that he decides on the direction and content of the sessions. It’s also interesting to note the emotional content of this moment – that Dibs, in a way, hands her astonishment. She hands back an explanation and answers his question. It’s a moment both inside and outside the playing. He moves out of the play of the sandbox and the playroom, asking her to answer why he’s there. She replies in a way that confirms the boundaries around his freedom to play. She doesn’t tell him what to do, or ask him why he’s interested, but confirms the space in ways that relate to the kinds of preparation talked of by Griffing: time, a safe space, appropriate materials and preparatory activities such as the notice assuring privacy. The kind of unpredictability, astonishment within Dibs’s and Axline’s interaction, is a part of the potential of this play space. So, in a way, Dibs is giving her the feelings he experiences of this as a place for anything to happen, to astonish. It also demonstrates to them both that the space is related to the world around them, but it is set apart from that world. Both things are true: the opening of the door, and the bringing in of the sign that says ‘No entry’, for me, symbolises this duality. The capacity of engaging in this astonishment lies alongside other factors in Smitskamp’s analysis of the task of the arts therapist in relation to the play space and the creative process: He must create an environment for the patients in which they can begin to experiment for themselves – however small and primitive those experiments may be at first. This demands a great deal of knowledge and experience of the therapist in the area of activity . . . It demands insight and [the] capability in the creation of play and play situations. It also demands the skill to actively follow, to wait, to let things happen; active in the sense of making things possible and being curious about the way a patient is going to express himself . . . (Smitskamp, 1989: 36)



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Read Johnson has allied the play space with the arts therapy space; each is ‘an interpersonal field in an imaginary realm, consciously set off from the real world by the participants’ (Read Johnson, 1981: 21). Many have also spoken of the importance of play’s role in mastering the separation and relationship between fantasy and reality, of play from life and the capacity to consider the relationship between specific experiences and generalisation, the capacity to conceptualise and make abstractions. This is not play occurring spontaneously; rather, paradoxically, it is the creation of a deliberate space for spontaneous play to occur in: ‘play processes are a part of a deliberate therapeutic programme for working with the client’ (Jones, 2007: 181). An additional difference is that the arts therapist will be present with the client throughout the process; the individual is not playing freely on their own. The play also has a goal: for the therapist and client to create play together in order to express, explore and work towards resolution of any issues brought into the therapy space.

Playing and playfulness The Investigac¸ão em Musicoterapia, Center for Training and Research in Music Therapy, which has been involved in work with the Department of Music Therapy at the Centro Regional de Salud Mental (University Psychiatric Hospital) of Rosario, Argentina, says that in music therapy each ‘unconscious sound identity’ of the therapist and of the client communicates with the other. It describes the relationship like this: Where they meet in the music, there exists a transitional area of musical forms, which cannot be attributed clearly to the one or the other, but which at the same time will be experienced by both partners as their own. The therapist has the task to help develop such forms, so that the client will be able to experience his own sound identity and the emerging deep unconscious material, without having to fear the burden of his responsibility for those forms. (Centre for Training and Research in Music Therapy, ADIMU website) In this way the arts therapies can be seen to create a framework – one that encourages such playfulness. This involves the creation of a ‘play space’ within the arts therapy session, as discussed in the last section. Here the client in the arts therapies can be said to have a playful relationship with reality, without the same ‘burden of responsibility’ as in the rest of their life (Jones, 2007). The playful state can be summarised as one that is seen to reflect aspects of the client’s experience, but in such a way that they can relate to the experience differently from the way they would outside the therapy. Bourne and Ekstrand (1985: 237–8) examine the importance of creativity in relation to this idea. Some of the uses they see in creativity being

208 Agents of transformation   stimulated include looking beyond what seem to be accepted boundaries, or a shift in perspective on a problem, for example. Creativity can also enable what they call a ‘shift in mode’ – if verbal thinking doesn’t help, then the exploration through making images might be of use. Another example they describe as creative ‘reasoning by analogy’, where a way of dealing with something from one aspect of someone’s life is applied to the current problem brought to therapy. Bolton talks about an awareness within playfulness that is interesting in relation to the arts therapies. He argues that play is not just about being lost or absorbed in the experience, that at the same time the player is aware of the relationship between their playing, themselves and the world outside the play. He describes a dual perspective, an active identification with the imaginary creation and what he calls a ‘heightened awareness’ of their own identification: ‘So, far from escaping from life, the quality of life is momentarily intensified because he is knowing what he thinks as he thinks it, seeing what he says as he says it and evaluating what he does as he does it’ (Bolton, 1981: 183). Bolton argues that reflection concurrent with identification leads to this heightened awareness and the potential for someone to learn about themselves and their experience. Play, then, can be seen to offer opportunities to do with entering into an intensified state. Playfulness refers to the ways in which a client can enter a state that has a special relationship with space, everyday rules and boundaries. This state enhances or permits spontaneity and creativity, frequently connected to playing. It is characterised by a more flexible, creative attitude towards events, consequences and held ideas. This enables the client to adopt a playful, experimenting attitude towards themselves and their life experiences. Smitskamp sums this up as follows: ‘Play and “pretend” situations often provide a great degree of structural security. In these situations feelings can be experienced extremely genuinely and intensively. The realisation that he was “just playing”, however, gives the patient the protection necessary to permit himself these feelings’ (Smitskamp, 1989: 35).

The play shift As we’ve seen, play can be characterised by specifc activities and by particular types of relationships between individuals. In ‘Play Behaviour in Higher Primates: A Review’ (1969), Loizos defnes the function of play for primates. She says it is a behaviour that borrows or adopts patterns that appear in other contexts within the primate’s life. In their usual place within the primates’ activities these ‘patterns’ appear to have immediate and obvious ends and goals. However, she states that: ‘When these patterns appear in play they seem to be divorced from their original motivation and are qualitatively distinct from the same patterns appearing in their originally motivated contexts’ (Loizos, 1969: 228–9). Here then a shift in meaning is seen to occur – I have called this the ‘play shift’ (Jones, 2007). This means that whilst many of the ways of behaving or doing things are seen to happen



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in play, their intention is different. So aggressive behaviour patterns may be shown, but they do not have the same intent as when they are displayed outside play. A child might play games that contain experiences from life relating to aggression or anger, but the emotions and situations would not be experienced by the child in the same way as they would be in their lives outside the play. Piaget (1962) echoes this when he says that in play the individual’s interest is transferred from the goal to the activity itself – to the enjoyment of the pleasure of play. Watson-Gegeo and Boggs’s observation of play in a Hawaiian neighbourhood includes a description of two children. In a fictive play the children were witnessed competing, contradicting, challenging and insulting one another. They argue that this was play reflecting scenes they had witnessed of parents challenging and accusing each other. They note that parents became involved in the play: ‘parents modelled and elicited playful contradictions with the children and encouraged their attempts. Children used the contradicting routine in their disputes’ (Watson-Gegeo and Boggs, 1977: 67). Garvey describes this process in relation to research into primary schoolchildren from Fiji: In one sequence the following shows a stepwise escalation of the content of the prior message– A: I can lift up this whole school. B: I can lift up our whole family. I bet you can’t lift up that with one finger. A: I can lift up the whole world with one finger. B: Well, I can lift up the universe. Since the children were pretending to have a quarrel, their communication and behaviour [were] more highly stylised than most non-play confrontations. The regularity of the patterning of exchange sequences reported in these studies, however, shows that the participants understood the underlying structure of verbal conflict. That competence can be used to enact a conflict within the pretend frame or in a more seriously motivated confrontation. (Garvey, 1984: 150–1) Schechner parallels the workshop experience with play. He argues that the workshop is a way of playing around with reality, a means of examining behaviour by ‘re-ordering, exaggerating, fragmenting, recombining and adumbrating it’. The workshop is a protected time and space where ‘intergroup relationships may thrive without being threatened by intergroup aggression’ (Schechner, 1988: 103–4). Garvey (1977) has argued that play is typified by what he calls non-literal behaviours. These are behaviours that are pretended. Though they have many of the characteristics of behaviours out of play, they are not the same

210 Agents of transformation   thing. Authors such as Bateson (1955) and Cohen (1969) have described a part of the way this functions as ‘metacommunication’. The idea is that a part of play involves an awareness and communication that the activities are not the same as in real life, that they are exploratory and safe. So someone can play angry: they have many of the characteristics that they would have if they were really angry, but at the same time, they give indicators that this is play, not ‘for real’. The notion of a play shift in the arts therapies is related to these ideas. In play as described by Loizos and Piaget elements of real life are retained but they are subjected to different motivations – enjoyment, exploration, assimilation: ‘the play shift involves reality being taken into the play space and treated in a way that encourages experimentation and digestion’ (Jones, 1996: 177). UK dramatherapist McAlister talks of a client, L, in an adult forensic setting. Initially they work within the sessions using story, object play and improvisation. However, the therapist notes of L: ‘he could not reflect on it at all’ (1999: 107). Work continues over a number of months. The client becomes increasingly interested in objects such as boxes and shells. L had previously commented that the hospital at times felt like a container. This led into work around what aspects of himself the client felt needed to be contained by the hospital and the therapy, and what parts wanted to be free:

Therapist’s account He was able to use objects to represent these things, the most signifcant being a small plastic dinosaur which he placed inside a box, fastened the lid and placed . . . underneath a table. This led him to begin talking for the frst time about his violence when ill . . . Following this, L began using fences and boundaries to contain the dinosaur so that it was out in the open yet still contained. Again these were themes that were returned to at later stages, as he continued to use various ferce animals to create stories about family groupings, zoos and captivity and reasons for his aggression. His capacity to make links between himself and session material gradually became much stronger. Eventually he was able to state, ‘I am the angry lion. That’s me. I’m an angry man.’ (McAlister, 1999: 108) She says that this area of play with objects allowed L to express and explore parts of himself symbolically. This work allows the kind of playful state described above, in which the client was able to look at and ‘to reveal areas of his psychopathology, i.e. his dangerousness’. As he explores and uses the space more deeply and as trust develops, ‘often diffcult and painful feelings surface’.



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Playful activity takes on meaning and the playful state allows the client to express and explore things he would not usually permit himself to do: For example, in one session we passed a ball and L began bouncing it hard. This developed into work expressing sounds and words as we bounced the ball back and forth, and L expressed a lot of anger in the exercise. Later he said the phrases he had used were the things he should have said to his abusers. (McAlister, 1999: 109)

Here the initial work seems to provide the client with the opportunity to play without creating overt connections to his life situation – the ‘protection’ described earlier, enabling L to permit himself to express and engage. He may also be seeing if the therapy space and his relationship with the therapist can be trusted. Once this safety has been established L seems to begin to work more deeply and to begin to allow areas of expression to enter into the play space that McAlister says he has not previously allowed to occur. In addition, L permits the spontaneity and creativity, described earlier as often connected to playing, to explore his feelings and situation. The play with objects such as the dinosaur, or with the ball, reflect aspects of the client’s experience. However, this is different from how he would express himself outside the therapy. L adopts a playful, experimenting attitude towards himself and his life experience. In the dinosaur work, for example, he allows himself to explore issues of his experiences and needs in relation to anger, aggression and containment. In the work with the ball he allows the spontaneous play to become suggestive of previous experiences and begins to say things within the play space and the therapeutic relationship that he could not say outside the therapy. The ‘play shift’ can be seen in the way that aggressive and violent aspects of the client’s experience are brought into the playful space. They can be reproduced, but are away from their original context. They do not have the same intent as when they were encountered outside the dramatherapy, and can therefore be expressed and experienced differently. They can, therefore, be explored in a more distanced way, the client can ‘look’ at himself within the space and the relationship with the therapist. In this way, for L, the ‘play space’ becomes an area that is both set apart yet connected to his everyday life. McAlister describes the positive changes in the client concerning his being able to communicate, to make connections, to manage his condition more effectively: ‘his capacity to make links between himself and the drama, reflect on our relationship and his capacity for insight’ (McAlister, 1999: 110).

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Play and development Arts therapists such as Aldridge and his colleagues do not see a developmental approach consisting of the notion of a series of stages that all children must pass through in areas such as cognition, emotion or relationship. They work with the idea that developmental stages can help them to see differences in individuals. This can guide the therapist in considering where issues may lie for individuals, and in looking at where work on development might assist the client in areas that are forming a diffculty. Maturation models of children used in areas such as assessment are criticised in that they have diffculty taking into account variability and individual differences (Jones, 2007). Each child needs to be seen in terms of the way they relate to these areas as individuals: Children select and transform what is meaningful for them from the context within which they find themselves. What is selected and transformed is in part in accordance with their cognitive abilities, yet these abilities are not separate from other related developmental processes. Each child may differ in his or her development. Furthermore, children not only take from the environment; they too give out signals that modify their environment. Infants give clues to their mothers about how they expect them to react. Improvised creative music therapy, with its emphasis on activity within a dynamic personal relationship, may play a role in encouraging development particularly when it focuses on communicative abilities. (Aldridge et al., 1995: 190) Here the child is not seen as a passive recipient of messages or norms concerning relationship and communication. They are seen as active within a relationship that forms. Each individual is seen as such, rather than as a child who should be performing in certain ways at certain times. An issue is framed in terms of development: if an area needs to be engaged with, this is seen as a challenge rather than a feature indicating some disfunction or disorder set against a generalised norm. So, for example, Aldridge et al. see work with children with learning disabilities as music therapy aiming to help ‘developmentally challenged children progress towards a richer communicative life’ (Aldridge et al., 1995: 190). The situation of the client is seen in terms of interrelated areas rather than as a disfunction owned by the child and defined by the professional. Aldridge sees delay as the potential consequence of a variety of factors – physical, mental or social. So, for example, issues might arise from experiences of rejection when standards or expectations associated with chronological age are not met. The relationship between a child and their social environment is recognised. A child’s situation is considered in terms of the ways in which communication differences can result in frustrations over developmental tasks



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and challenges in areas such as being loved, stimulated and educated. Aldridge et al. say: ‘Our therapeutic task is to respond to abilities and potentials so that those limitations themselves are minimised. If both environment and individual are important for developmental change, the therapist provides, albeit temporarily, an environment in which individual change can occur’ (Aldridge et al., 1995: 190). The idea is that music can assist developmental change. Their study used a structure to look at a variety of areas of the child’s communication to see if changes were occurring as a result of coming to music therapy. The therapists saw these areas as giving information on developmental change. These included the relationship between child and music therapist, and the state of musical communication: whether the relationship manifested total obliviousness, or some response or mutuality in playing music, for example. Musical communication included looking at the child’s use of instruments and vocal activity along with body movement. These are seen by them to be interrelated: ‘musical dialogue in the music therapy relationship seems to bring about an improvement in the ability to form and maintain personal social relationships in other contexts’ (Aldridge et al., 1995: 203). They emphasise that they did not use music to try to manipulate children so that particular goals in communication, or their use of an instrument, were met. They are interested in what, if any, developmental changes took place within the opportunities offered to the child by the presence of both musical instruments and the therapists. Here is an example of how they understand this approach: the active playing of a drum demands that the child listen to the therapist who in turn is listening to and playing for him or her. This act entails the physical co-ordination of a musical intention within the context of a relationship. We would argue that this unity of the cognitive, gestural, emotional and relational is the strength of active music therapy for developmentally challenged children. (Aldridge et al., 1995: 203)

Conclusion This chapter has shown how processes such as the ‘play shift’ and the creation of a ‘play space’ are central to ideas of change in the arts therapies. As we also saw, Harris challenges the idea that playing is only important for children. He argues against the idea that pretend play and fantasy is something characteristic of young children and that by adulthood it has mostly disappeared, asserting that this is wrong: ‘Human beings have a gift for fantasy which shows itself at a very early age and then continues to make all sorts of contributions to our intellectual and emotional life throughout the lifespan’ (Harris, 2001: 1). It is also seen by him to be important in comprehension. He says that when an adult listens to a narrative, they build

214 Agents of transformation   a mind’s eye mental image or model of the situation or events. It’s the mental model that remains, not the words. This, he argues, is allied to the play space and pretend play in children as ‘a time and place that is removed from their current situation’ (2001: 1). As we have seen, this is akin to the function of the transitional space connected to Winnicott’s concepts. At the heart of this is an ‘interweave’: No longer are we either introvert or extrovert. We experience life in that area of transitional phenomena, in the exciting interweave of subjectivity and objective observation, and in an area that is intermediate between the inner reality of the individual and the shared reality of the world that is external to individuals. (Winnicott, 1974: 75) This concept sums up much of what is important to therapeutic change in the arts therapies. The arts therapy space and the arts therapist enable clients to inhabit a space between internal and external, where playfulness can be brought into contact with areas of difficulty, or that are in need of development. Cattanach describes this space as a kind of gap: ‘It is in this gap between art and life, in a sort of timeless space, that we can experiment with ways of being which can help and heal both individual and group’ (1992: 3). This is the arena of the ‘play space’ and the ‘play shift’, used by all clients in the arts therapies.

fourteen

From the triangular relationship to the active witness: core processes in the arts therapies Introduction An art therapist sits in a room with her client, between them a piece of paper – unused as yet. A dance movement therapist and a client are about to enter an improvised sequence of movements together. In a studio a dramatherapist and group stand in a circle, waiting for a theme to emerge. A client in music therapy begins to try out different instruments, passing them to the therapist. Between therapist, client and art form, in each of these situations, is the tension, the space, for something to happen and for change to occur. As we have seen in Chapter 13, this ‘potential space’ is at the core of the arts therapies. The opportunities that artistic expression and arts processes create within a therapeutic space and within a therapeutic relationship offer unique possibilities for clients. Any description can only be a metaphor for the true process, but Part III has explored how these potentials for change have come to be understood, and how they can be used. The descriptions and discussions have looked at specific aspects of arts therapy work and form. This chapter tries to summarise what makes the arts therapies so innovative and so effective. It tries to encapsulate the specific and unique ways in which therapeutic change can occur in the arts therapies. In brief: what is special about the arts therapies? What is it that is especially useful for clients? It’s important to try to find a balance between creating a language that obscures or is over-technical and a way of describing that is precise enough, that does justice to the processes at work. The following, then, is a series of ‘core processes’ that tries to be precise, without creating a way of describing how something works which becomes opaque or baffling in its complexity (Jones, 1996; 2007). Nor is the idea of these ‘core processes’ one that is designed to be prescriptive, with fixed ideas about how they should be applied. Each therapist will use their creativity to relate to how they would be reflected in developing work with clients. Many arts therapists would find Greek

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216 Agents of transformation   dramatherapist Couroucli-Robertson’s position a familiar one. Areas of process and practice are common; however, each encounter has an original, fresh creative component: ‘Through the years I have developed a personal mode of working which I try to adapt to different clients in order to meet their own individual needs’ (Couroucli-Robertson, 1997: 143). The definitions also try to do justice to the things the arts therapies have in common, whilst not denying the differences between art, music, drama and dance movement.

The arts therapies core processes These processes are: Artistic projection The triangular relationship Perspective and distance Embodiment Non-verbal experience Play and the playful space The participating artist-therapist Active witnessing.

Artistic projection A client creates something in an arts therapy session, or there is the intention or resistance to creating something. Whether art work is being created or not, the act of creation through an art form is always immanent or present. This can involve an image, an enactment, a sound or a movement. The process of creation, and whatever is created within the empty paper sheet or the empty movement space, has a therapeutic potential. This importance arises out of the relationship between the client, their creation and the therapist. One key element of this relationship concerns the way the client connects with the work they produce: what the process of making and the product becomes to them, and the effect the process and product has on them. Authors such as McCully (1987) have paralleled aspects of archaic art and Rorschach inkblot tests in terms of offering what can be called ‘projective possibilities’. Wilshire echoes this, in talking about theatre, when he says that people can see themselves reflected in the interactions between characters on stage. He adds that in seeing aspects of oneself reflected a change can occur: ‘to come to see oneself is to effect change in oneself in the very act of seeing’ (Wilshire, 1982: 5). This ‘seeing’ is equally true for many art forms and is relevant to understanding one of the processes common to all the arts therapies. This concerns the process of artistic projection.



  Triangular relationship to active witness 217 I have described such projection in dramatherapy in the following way: The process by which clients project aspects of themselves or their experience into theatrical experience or dramatic materials or into enactment, and thereby externalise inner conflicts. A relationship between the inner state of the client and the external dramatic form is established and developed through action. The dramatic expression enables change through the creation of perspective, along with the opportunity for exploration and insight through the enactment of projected material. (Jones, 1996: 100)

For classic Freudian or analytic thinking, processes such as projection and projective identification are primarily defensive (Klein, 1932). Analytic psychotherapist Theilgaard, in her chapter in Shakespeare Comes to Broadmoor, describes this projection in the following terms: ‘specific impulses, wishes, aspects of the self are imagined as being located outside the self’ (Theilgaard, 1992: 164). Thielgaard talks about the ways in which drama can parallel the process of the Rorschach test. The Rorschach test uses inkblot shapes as ‘a unique vehicle for observing aspects of both perceptual and verbal processes. It illustrates how an individual structures the inkblot, so that we are given an impression of the perceiver’s inner world’ (1992: 170). She points to the ways in which the stimuli of images and created art forms can offer ‘an excellent instrument for projection’ (1992: 171). For the arts therapies a vital relationship is created between inner emotional states and external forms and processes in this way. As Chapter 12 illustrated, projection allied to expression through the arts within the arts therapies operates as a developing, ongoing process. The client projects material into the art form or process. This enables the expression of material and also, crucially, the opportunity for exploration. Material that had previously been held unexpressed, for example, by the client can be expressed and held by the art form or process. This expression through the arts can be a conscious decision made by a client in order to explore an issue or area, or it can occur in a less direct, or deliberate, way. The client might make a deliberate decision to create an image or a roleplay or movement sequence relating to a specific issue or aspect of their life. They might, alternatively, be engaged in the creation of images or work without deliberately naming an area or issue: the making of images or movements without a conscious intent or direction. In both situations the client relates to the art processes or products through artistic projection. This expression can lead to, or allow, exploration. The art form and the relationship within the therapy can encourage the client to work with material. This exploration can lead to a new awareness, or relationship, to the material brought. This new position can then be integrated into the client’s experience of the issue. Dramatherapist Mond, practising in Israel, quotes one of her 12-year-old clients who had been involved in a traumatic road

218 Agents of transformation   accident, who talks of their experience in a way that illuminates this process of artistic projection: ‘Dramatherapy is about touching and playing with objects, drawing and telling stories and making up plays about them. This lets you collect up and get out the frightening feelings from inside you and doing this helps you to be calm’ (in Mond, 1994: 184). UK art therapist Levens illuminates the ways in which this process can release, contain and transform in describing her work with clients with eating disorders: Art may be seen as an extension of the self and as a psychological double with the property to ‘mirror’ the self. The art therapist needs to be aware that this reflection is not a static statement of the patients’ inner world, but that he or she, unintrusively, may help the patients to use their work as an on-going process, to introduce the concept of time and space and continuity, in which their work can develop and change. In essence, patients for whom there is a lack of stable bodily self may be able to use art therapy, particularly the development of line and form, as an external structure enabling the development of a more stable internal structure. (Levens, 1990: 283–4) I would argue that the projection into an object, art form or arts process in the arts therapies need not only concern aspects of the self. Important others or aspects of their life experience, or the client’s relationship with the therapist, can also be projected into the image, or movement, or sound. The processes described by Levens and Mond’s clients, and this broader understanding of the way clients can project into art forms, are similar. In this way artistic projection can be understood as an ongoing process: one whereby expression is connected to exploration and the development of a new perspective through this expression and exploration. Redhouse (2015) analyses her work with Iris, who had been referred to a hospice in 2011 at the age of 72 with a diagnosis of cancer; she was admitted to the wards for symptom control and psychological support. Her referral included her expression that she wishes to engage with her life-story. Redhouse describes part of the work in the following way: Iris’s childhood centred round her paternal grandmother’s house and her many cousins. In order to provide a visual map of this I suggested that Iris used beads, shells and stones to represent her family members. The selection of differently sized and decorated objects also revealed something of the emotional quality of the relationships; for example ‘Nanny Baines’, the matriarch at the centre of the family, was depicted as a large floral bead. Iris moved the various ‘characters’ around in her description of alliances and groupings, and in doing so recalled how she used to



  Triangular relationship to active witness 219 perform plays with her younger cousins in the streets where she lived. Another aspect of this . . . is that the scene was not tied to chronology, but represented Iris’s significant family relationships. Thus her biological father (who died when she was five) and her step-father (who became an emotional father to her) could both be in the small world she created. (Redhouse, 2015: 72)

Redhouse describes this as Iris projecting aspects of herself into the materials and as involving a relationship with the therapist; as Iris works with the objects it ‘enables the creation of different perspectives, and . . . the small world created becomes a shared playful experience for therapist and client’ (2015: 17). She also links the work of the creation of such images to Chipman’s photography work in the arts therapies and for client and therapist to be witnesses to the client’s world and relationships: ‘Chipman discusses the importance which looking at the self can have for cancer patients in her case study “Self-portrait photography with a young adult living with cancer”, stating that for her client, “the photographs also became the witness of what she had lived. They serve as memory or narrative, as proof that she struggled, lived and survived” (2010: 121)’ (Redhouse, 2015: 17). The presence of the art form and the client’s involvement through such artistic projection offers specific opportunities within therapy. The use of artistic expression might enable discoveries, or create connections for the client that minimise the cognitive, discursive processes that are often associated with verbal language. This may allow the associative freedom of image creation, or movement, and the particular combinations of feeling and creativity that art processes can facilitate. This process can be seen as one that allows expression and exploration of material, followed by a new relationship to the original issues. The process allows the client to integrate the exploration back into their experience of themselves or their lives, and to link the discoveries or processes to their sense of who they are and how they live. Artistic projection offers the client the opportunity for involvement in the issues they bring to therapy, for seeing and exploring material. It is the process that enables the client to become powerfully engaged in the arts products and processes within the therapy. The client can use art, music, drama and movement processes and products within the therapeutic relationship to express and explore personal material or life issues. Artistic projection as a term sums up the particular qualities of painting, role-play, musical improvisation or bodily movement to engage, reflect, hold and transform emotional, psychological and communicative experiences for the client within the arts therapies.

The triangular relationship As Part IV has discussed, many forms of therapy involve the therapist and client talking together. This form of communication and relating is the

220 Agents of transformation   basis of several elements that are seen to combine to bring about change. Talking is the primary way client and therapist communicate; it forms the main route through which the relationship emerges. The arts therapies profoundly alter this. In all the accounts of arts therapy given so far, one of the themes which has emerged is the notion of a triangular relationship. The therapy is not about the therapist and client alone – the arts process and product have a key role to play within their relationship. Particularly in art therapy, this is often referred to as a ‘triangular relationship’. One important way this happens is that an art form enables something different to occur as an arts process or created product emerges within the therapy room. Some arts therapists, as we have seen, place an emphasis on the presence of the art object or product within therapy. Others assert that this triangularity need not rely on a created product alone; they argue that the arts process itself, of dancing, music, drama or art, creates an element additional to the therapist and client. Either way, the client and therapist’s experience of therapy is shifted in crucial ways by the presence of this ‘third’. An object may be created or used within the therapy room and within the therapeutic relationship. In art therapy this can be a made object such as a painting or a sculpture; in dramatherapy objects such as toys or puppets; in music an instrument can be used; in dance movement therapy cloth can be moved with, or masks worn. It’s not always the client who creates or uses these objects or artefacts. As we have seen, in some forms of the arts therapies the therapist paints, dances, makes music or acts. This involves the therapist using their creativity through participation in relation to the client, and there is a mutuality in making, using or responding. The idea is that this third presence alters the dyad of therapist and client. Here Evans and Dubowski draw on this ‘triangle’ as a concept in their analysis of art therapy involving children on the autistic spectrum: The art materials and art-making processes are an integral part of the art therapy from the beginning of treatment. As such they are one of the most important elements in the art therapy as they provide an indirect focus and shared engagement between therapist and client. By directing social interaction through a focus on art-making activity, a form of relating which children with autism can tolerate, and build up a tolerance for, becomes established. (Evans and Dubowski, 2001: 100) Music therapist Levinge summarises her practical understanding of the triangular relationship as follows: Whether working with a child or adult, my primary concern is to use music to enable both the patient and me to find a way of being together – that is, to develop a relationship – which makes sense to us both. The three elements involved



  Triangular relationship to active witness 221 in this process are myself as therapist, the instruments and the music. The ways in which these are used depends on the nature of the patient’s problem. (Levinge, 1996: 237)

Here the triangule is created by the involvement of an object and by the presence of the arts process. The arts form and arts products allow an additional factor to enter the relationship between therapist and client.

Perspective and distance Sometimes, when someone is in trouble and comes to therapy they can feel overwhelmed by their problems. It’s as if they are completely inhabited by them, it’s the foremost thing they’re encountering in their life. Perhaps they have been living with something for so long it’s hard to see any other way of being. Perhaps the past feels as if it has happened and it’s stuck, fxed, immovable. Others might feel frozen in some way, cut off from their life, themselves or their past. They might deny any connection – they might be experiencing physical pain for which there’s no medical reason, but which may be a cut-off expression of buried emotional, or psychological, pain. Perspective or distance can be essential elements within arts therapy work, and can be vital in assisting clients in such situations. One of the ideas that is common to the arts therapies, and is described in different ways by different practitioners, can be thought of as ‘perspective’. Looked at in one way, all therapy can offer perspective if that is seen to mean some time to be apart from the everyday run of life, in a special space and in a relationship with the therapist, or with other clients, that is devoted to exploration and change. Distance and perspective here, though, means that by working with the arts in therapy it is possible for the client to achieve a particular state or relationship to themselves and their experiences. This has been described as ‘aesthetic distance’ (Landy, 1993). As we’ve seen in the case material within Part IV, one of the important facets of all the arts therapies involves the way a client becomes engaged in the arts. This involves both the creative process as the arts expression emerges, or occurs, within the therapeutic relationship between client, art form and therapist. If, for example, I have painted an image, it can both connect deeply with something that has happened to me, or can express or explore an aspect of my sense of who I am. Expression in the arts therapies can involve many different relationships to creating. It can involve momentary spontaneous object play or a choreographed piece of dance. It can vary from a briefly made sound, through to a painting which is worked on over a long period of time. What most matters is that the client can become creatively and emotionally connected to an expression described earlier as artistic projection. This expression is seen to be related to the reasons the client is coming to therapy.

222 Agents of transformation   Dramatherapist Landy has developed the theory of aesthetic distance in the arts therapies. This involves the concept that ‘overdistancing’ involves keeping too rigid boundaries between self and other; ‘underdistancing’ involves identifying too readily with others, losing a sense of clear boundary between self and other. Therapy can involve aiming for a balance between the two: a balance between self and other where boundaries are flexible and change is possible. This point or state is described by Landy as ‘aesthetic distance’: When the individual is at a point midway between two extremes of overdistance and underdistance, he is at aesthetic distance . . . At aesthetic distance, the individual achieves a balanced relationship . . . he is able to experience a confluence of thought and feeling, to ‘see feelingly’, like the blinded Gloucester in King Lear . . . one retains a piece of the overdistanced, cognitive observer and a piece of the underdistanced, affective actor. (Landy, 1994: 100) It is this state that the arts therapies can offer to the client. Perspective and distance concern: • • •

the ways in which arts expressions create perspective the ways in which arts expressions connect a client’s life experience with the material in the session the way in which the expression allows new opportunities to achieve a different perspective for the client.

Expression through the art form and process within therapy enables the client to take part in something that is both of their lives, but is also separate from their lives. To create an image, musical improvisation or a dance based on their lives is a part, and an extension, of their life. However, the fact that it is an expression created in an art form allows the particular qualities that artistic experience brings to be put in contact with the issue or life material. For a client in the arts therapies the issue of distance or perspective can operate in a variety of ways. For the client who is overdistanced or separated from their life experiences and feelings this can be a way to increase engagement – the painter rather than the viewer, the actor rather than the audience. For the client who feels overwhelmed, the experience can help to engage with the parts of themselves as viewer, listener and audience or witness – and to look at their experience in a more dispassionate way. The notion of distance means that the client can arrive at an expression that allows them to become maker and reader, painter and viewer, dancer and audience member to their experiences. The artistic experience within a therapeutic framework can assist the client in creating perspective, which can assist them in engaging with their lives, or parts of themselves, in a different way. Philosopher Langer, writing about music, talks of detachment



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and attachment in a way that summarises a key aspect of this process: ‘Music is not self-expression, but formulation and representation of emotions, moods, mental tensions and resolutions – a “logical picture” of sentient, responsive life, a source of insight, not a plea for sympathy.’ She adds that when ‘psychical distance’ has been achieved, the content has been symbolised for us, and what it invites is not emotional response but insight: ‘Psychical distance is the experience of apprehending through symbol what was not articulated before’ (Langer, 1952: 216, 223). It is this process which the arts therapies can offer the client. The arts process within the therapeutic relationship can enable the client to discover needed change. They can explore the ways in which by becoming artist and viewer, actor and audience to their lives they can discover a new relationship to themselves. This changing of roles, this creation of different perspectives, can transform the way they see themselves and their life. The arts enable this within the therapy, owing to the specific demands and possibilities that artistic processes and relationships offer.

Embodiment Embodiment in the arts therapies concerns the ways in which someone’s body relates to their identity. The body is also seen as a primary means by which communication occurs between one person and another. This can be through gesture, facial expression or voice, for example (Elam, 1991). Embodiment in the arts therapies embraces the ways in which clients communicate both consciously and unconsciously through their body. Sociologists have considered how identity is connected to ‘the ways in which the body is presented in social space . . . some consider that the self presents selected personae in different situations and arrives at a sense of identity through bodily expression and behaviour in relationship to others’ (Jones, 1996: 113). For some clients ‘knowing with the body’ is something that is underused or undervalued. For others, for whom verbal language is not the best means of exploration or communication, non-verbal work rooted in physical experience is an important part of the arts therapy process. Courtney, for example, speaks of the importance of knowledge ‘gained not through detachment, but through an actual, practical and bodily involvement’ (1988: 144). Issues can be encountered and realised through physical embodiment – expressed and explored through the body. Part of this involves the physical encounter of the active involvement in an arts experience such as dance. The client can combine physical engagement and mental reflection or analysis, connecting the knowledge to be gained through sensory and emotional feeling with the knowledge to be gained by more cognitive perception. The arts therapies can also focus on aiding the client to inhabit or use their body more effectively. This might concern how clients communicate with others, for example, described by Jennings as individuals who have

224 Agents of transformation   difficulty ‘in using their bodies in positive, effective, creative ways’ (1973: 27). Another area concerns the way in which the client takes on a different identity within the arts therapy. In dramatherapy or dance movement therapy, the self may be transformed by taking on a different identity, or encountering forms of expression the client does not normally allow themselves, or that they are not allowed by the strictures and constraints given them by society. This physical transformation can enable insight, new perspectives and release that can result in changes in the client’s life outside the exploration in the arts therapy, in the client’s life as a whole. This can happen, for example, in creating a character in dramatherapy or exploring the way movement relationships develop in dance movement therapy. An experience brought to therapy might be only, or best expressed through the body. Verbal language might not be able to describe the experience – it might not yet have words, for example. The work with the body in therapy might be the only way a client can bring the material into the therapeutic space. Alternatively, the client might not be able to use verbal language and therefore physically based work and communication might form the way in which the therapist and client find a way to communicate using the language of the client. Examples of this might include clients with severe learning difficulties or clients with Alzheimer’s. Another aspect concerns the exploration of the personal, social and political forces and influences that affect the client’s experience of their body. Here the arts therapy process and space offer the opportunity to explore through different expressive forms areas such as body image, or emotional traumas related to the body. Here, for example, the client might create a life-size painting depicting their feelings about their body, or a sculpture of a part or whole of themselves; they might depict their body, or explore material physically through movement and sensory work. Mackenzie, in her therapeutic work with an arts therapy programme in Australia for children aged 4–14 years who have been affected by trauma, reports on art, music and dramatherapy group work with the children: In Week 4, the therapy team introduced a story, ‘The Big Ugly Monster and the Little Stone Rabbit’ by Christopher Wormell (2005). It was chosen because it explores themes of friendship and loss that had been expressed by the group in the previous session. The aim was for the story to create dramatic distance so that personal themes could begin to be safely explored. As the Dramatherapist, my role within the team was to tell the story. The Art Therapist then invited the group to create an image from the story and finally the Music Therapist offered music as a way to reflect on the pictures created. Claire listened intently to the story. She drew an image of the stone rabbit who was left behind by his friend who Claire stated had died.



  Triangular relationship to active witness 225 Once the artworks were complete the group was invited to reflect on their artwork using musical instruments. Claire sat at the drum kit and played a repetitive beat lasting for several minutes. On completion she stated that her brother has died and she can’t speak to her mum about it because her mum is always crying. The group sat quietly and listened intently to her story about her brother. When Claire had finished speaking the group began asking her questions about how he had died which she did not want to answer. Perhaps this was associated with shame surrounding suicide. The therapy team was aware of her need to talk and be heard by the group as we suspected that due to her mother’s sadness, her brother was often not spoken about within her family. In closing the session, the group came together for the familiar closing ritual, where Claire and the other group members were invited to verbally reflect on the session before singing a goodbye song. (Mackenzie, 2013: 136–7)

Mackenzie analyses the nature of change as centring around embodiment in relation to the arts forms and the therapeutic process. She draws on a variety of arts therapies theories to frame Clare’s process: Jones (2009) highlights . . . embodiment . . . as a tool of communication and identity both consciously and unconsciously. Art therapists refer to the embodied image (Schaverien 1990) as opposed to a descriptive image whereby the embodied image is invested with more affect or unconscious forces and music therapy supports embodiment through rhythmic movement. However, Dokter (2010) concludes that ‘being witnessed in the embodiment is most strongly present in dance movement and dramatherapy, where there are no images or instruments to distract attention’ (Dokter 2010, 222). Within this setting, Claire might find her body taking on a character or role, inhabiting an imaginary world, physically moving in new ways throughout the therapy space, and engaging in embodied play. Here embodiment . . . allows access to and the expression of feeling. (Mackenzie, 2013: 137) Such embodiment offers a perspective on experience that allows the client to bring, or access, material physically, to explore experience through the body within the therapy space. It enables client and therapist to work through aspects of the arts that involve embodiment to create an arena for expression, exploration and change. Some would go so far as to say that

226 Agents of transformation   specific aspects of experience can be expressed only through the body – that words cannot effectively engage in the same way: Some theorists would propose that communication through creative art forms is the only way of giving expression to the material of primary process, and that the use of discursive language must always be restrictive. Certainly for all of us our bodies and their movement become symbols for much of our feeling and our experience of groups is felt in the bones more profoundly than it can be described in words. (Holden, 1990: 270)

Non-verbal experience As we’ve seen in the descriptions of the core processes so far, the use of an art form – painting, playing a role, creating music – creates a language that differs from the spoken word. It offers a different way of encountering the clients’ experiences; it offers a specifc way of communicating those experiences. By ‘encounter’ I mean that an art form depicts experience in a way that differs from spoken language alone. For some people words have particular properties – they can, for example, feel very ‘direct’. I find this a strange idea – as an art product can also feel very direct. I would rather say that the directness is different. By this I mean that the art form enables a specific kind of ‘in the moment experience’ through the creation of artistic, physical engagement in the room with the therapist. An image or sound or enactment of an experience is different from a verbal description alone. Aldridge (1996: 268) points to the value of music being ‘without the lexical demands of language’ as a key factor in communicational improvement. The art form allows the emphasis of communication through rhythm, articulation, sequence, pitch, timbre and physical expression through means such as hand movement and gesture. He points to research indicating that musical dialogue in the music therapy relationship seems to bring about improvement in the ability to form and maintain relationships in other areas of a client’s life. Kristeva has attempted to describe a difference between verbal and what she describes as ‘transverbal’ communication: It seems important to me never to neglect the transverbal dimension in communication, to take into account the visual factor, the plastic aspect of the icon as signifier, which lends itself more readily to playfulness, to invention, to interpretation, than verbal thought, which can have a repressive intellectual weight. (Kristeva, 1986: 44)



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The arts-based engagement between client and therapist can mean that the client becomes an expressive, creative, active partner in treatment. This can affect the relationship: one aspect is described by Sharma as involving the client becoming ‘much more active than most orthodox doctors would envisage or desire. In such a case the term “patient” perhaps requires revision; sick people “suffer” their sickness, but are not “passive” in their suffering’ (Sharma, 1994: 101). It allows the client to bring material through image, enactment, movement or sound, not through verbal language alone. This enables opportunities to encompass experiences for which words are not appropriate, or cannot be found by the client. McFee and Degge (1977) talk about the difference between making involving the arts and thinking about something: when people make art they are symbolising their experiences in an art form. They say that art enables new insights about experiences to occur: How is this different from just thinking about experiences? It enables people to express what they might not be able to say with words. When people say that they are at a ‘loss for words’ they may mean that they have had an experience that is so rich in details, in meaning, or in emotional quality that they cannot describe it. If people have learned to use art expressively, the essence of their response can be expressed graphically. They can refer back to their art many times to analyse the ideas and emotions they expressed, thus gaining insights into their own development. (McFee and Degge, 1977: 273) Murphy (1998) talks of the particular use of visual images in relation to memory and certain kinds of experience relating to childhood sexual abuse: The use of visual language could be said to have particular relevance: research shows that traumatic memories are encoded in a ‘primitive visually-based memory that records an event as a whole’ (Johnson, 1987). Verbalising experiences may present problems because . . . the abuse happened at a pre-verbal level of development (Young, 1992) or the child may have been warned by the perpetrator of life-threatening consequences if they speak about the abuse. (Murphy, 1998: 10) She argues that art therapy can access issues in ways that enable boundaries to be maintained. The properties of art materials, for example, lend themselves to expressing and exploring non-verbal experiences and can facilitate the expression of suppressed feelings. Expression and exploration can be followed by integration: ‘the embodied image can contain projected

228 Agents of transformation   feelings and become a scapegoat which can be preserved, or destroyed without harming anyone’ (Murphy, 1998: 11). Here, the non-verbal nature of aspects of the arts therapy experience is seen to offer particular opportunities to the client. As Jennings et al. (1994) say, ‘most psychotherapy and psychoanalysis relies on existing language and especially the language of words; however, it is possible to discover completely new means of communication through intensive work on the body and voice’ (1994: 105). Such innovative practice can offer opportunities to explore particular kinds of experience that either do not relate to words or are not ready for verbalisation, but which need to be communicated and worked on within the therapeutic relationship.

Play and the playful space As we have seen in Chapter 13, studies of play have highlighted its link to change. They focus on play’s capacity to refect life experiences: to offer opportunities to create states that are apart from, yet connected to life outside the play. Research has also shown that, when engaged in play, our ways of relating to events, people and ourselves can change, ‘a generalised transfer of a playful attitude or a fexible response set from the play to problem-solving situations. Hence children with play experiences may be more fexible, curious, spontaneous and interested in the task’ (Jones, 2007: 143). Secondly, there may be a more specifc transfer of novel responses generated by investigation and experimentation in play: transferring some of the things discovered in play activities to other situations in their lives. The cognitive skill of shifting one’s thinking from concrete to abstract during play may be similar to the skill required to generate a variety of novel responses on a divergent thinking task (Johnson, 1976: 69). As we saw, analyst Winnicott has been influential in the ways that some arts therapists have grown to understand their relationship with clients in terms of the idea of a ‘play space’. His ideas are sometimes used as a starting point to explain the arts therapy space: the nature of the contact between therapist, client and art form. His emphasis on the importance and function of play – between baby and mother, for instance – has been linked to some of the discoveries and ways of connecting which have emerged in the arts therapies. He has also said that therapy is ‘to do with two people playing’ (Winnicott, 1974: 44). Minsky (1996), along with others, draws attention to Winnicott’s connecting the child in play with their mother to the patient’s relationship to the therapist. Minsky links both to artistic processes: ‘Winnicott took the view that play, and the artistic imagination and enjoyment of art, take place in the same psychical space’ (Minsky, 1996: 123). As we saw in Chapter 13, this notion is interestingly developed in Winnicott’s suggestion that the division into inner and outer reality is inadequate – that there is a third intermediate state where phantasy and reality meet. This idea of such an intermediate space is an important one for the arts therapies.



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Blatner’s definition of creativity is one that is useful to consider in relation to the idea of the playful space. He says that creativity refers ‘not simply to art or science, but to the activities of everyday life, in relationships, in societal institutions, and in personal and spiritual development’ (Blatner, 1997: 152). The therapist and client inhabit a space where artistic expression and arts processes can enhance both client and therapist’s creativity. The therapist and client play together – they enter a playful relationship where phenomena associated with play and playfulness can enter the therapy. This allows a playful relationship to occur. This is typified by flexibility: an experimental attitude where cause and effect can be explored, without the actual consequences that might occur in the client’s life outside the therapy space. Cattanach describes this as an arena where it is possible to ‘develop new meanings for ourselves uncluttered by the constraints of our own reality’ (1994: 34). In some situations the therapist and client can be seen as ‘co-players’ – joining in activities together. In others the therapist can hold the play space, maintaining boundaries, attention and, in some cases, adopting an interpretative role to enhance the discoveries and insights being made by the client. This is brought to the playing role of the therapist within the play space. By this I mean that the arts therapist attempts to be an informed player – bringing their knowledge and creativity to the playful space for the benefit of the client. The creation of a play space in the arts therapies involves the creation of an area set apart and yet related to the everyday world. It has specific rules and ways of being. The client in the arts therapies can be described as having a playful relationship with reality. This does not necessarily refer to a humorous response to real life. Playfulness in the arts therapies concerns the ways in which a client can enter into a state that has a special relationship to time, space and everyday rules and boundaries. This state can involve a heightened degree of spontaneity and creativity frequently associated with playing. This playful relationship with reality is characterised by a more creative, flexible attitude towards events, consequences and held ideas. This enables the client to adopt a playful, experimenting attitude towards themselves and their life experiences.

The participating artist-therapist Skaife asks the question: what does the art therapist do whilst the group is painting? She advocates the practice of the art therapist following the aesthetic activity of the clients ‘to enter into the painter’s experience of the members and to free associate with it – to enter into the painter’s experience of making the painting as though one were making it oneself’ (Skaife, 2000: 137). She says that in her experience she has found out a great deal about what is going on by working in this way. Art therapist Wadeson describes how a severely depressed man she was working with had become mute after a suicide attempt: ‘I found that although a verbal interchange with him was impossible, we were able to communicate non-verbally by making several

230 Agents of transformation   pictures together. In them I followed his lead, responding with colour, form, or symbol to his graphic ideas as we took turns adding to the picture’ (1980: 42). This is parallel to the therapist taking on a role in dramatherapy or the therapist playing an instrument at the same time as the client in music therapy, or the dance movement therapist engaging in movement. Callaghan allies the arts with innovation, saying that the creativity of the art form enhances the potentials of the relationship: ‘the arts are inherently radical and encourage creative exploration. These factors can help individual movement psychotherapists to resolve conflicts between traditional models and the new approaches necessary for working with torture survivors and other similar groups’ (1996: 262). She cites as an example of this the fact that movement therapists participate in actively moving with clients, mirroring or taking part in their movement patterns or forms. She says this mitigates the seemingly disengaged and passive quality of ‘Western-style’ therapists, which people from other cultures might find alien. Callaghan (1996) draws on these concepts in analysing her dance movement work with survivors of torture. Her account features practice with a Kurdish man from Turkey and a man from Bangladesh who had virtually no verbal language in common. In a session they ‘shuffled despondently from side to side doing Middle Eastern dance-like movements’. Callaghan describes how she shuffles with them. A brief comment from the clients about a feeling of going nowhere is followed by her introducing a slight change in the shuffle, moving into a ‘regular, rhythmical side step’. Callaghan sees her participation in dance with the clients as a crucial factor in the therapeutic. The arts therapist can participate in the art form as a way of enhancing the client’s experience of therapy, for example by moving with the client, taking on roles, or playing music. The therapist can engage in an art form as a way of communicating to the client, as the case examples in Chapters 15 and 16 will show. In such situations the therapist, by making music, by creating with a client, forms routes of contact and transformation through active participation.

Active witnessing Casson (1997) says that being a witness to theatre ‘is a strong stimulus and [is] able to bring into consciousness things we have either not experienced or have avoided or repressed. We may then be confronted with the shock of an encounter with both intrapsychic and interpsychic material that challenges us, facing us with imaginal and real truths’ (Casson, 1997: 47). Grainger adds to this, observing that ‘objectifying awareness by giving it an independent existence apart from oneself is recognised by creative therapists as inherently therapeutic . . . they locate healing in personal relationship – in other words, in “what is between” self and other. That they value objectifed self-expression as a means of making contact with whatever is not the self, bridging the gap of otherness . . . the function of art to stand apart and



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involve at the same time’ (Grainger, 1999: 11). In art therapy Schaverien has talked of a similar dynamic concerning the viewer and artist within the client: The picture offers an alternative external presence, it is an object which exists outside of the artist, and yet a part of her or him temporarily inhabits it. A split is made between the part of the person who makes the picture (the artist part) and the part that views the picture (the viewer). (Schaverien, 1992: 19) The client is seen as being absorbed in the picture during the making as the ‘artist part’: then the ‘viewer part’ comes to the fore and the ‘artist’ watches whilst the ‘viewer’ responds. She allies this with the artist-self ‘making a transference’ to the picture, and the viewer-self being like the therapist ‘bringing a more objective response to the picture’ (Schaverien, 1992: 19). This aspect of the self looks at meaning and implications, making links. This is seen as contributing to the process of change, a self-analysis occurring, and as a particular way in which transference and counter-transference develop, linked to the witnessing aspect of the client’s experience in therapy. McClean talks about an aspect of this process in art therapy with clients who are dealing with drug dependency. In describing the specific benefits of art therapy she says that ‘emotions can take on concrete aspects which are “contained” and held in imagery. This is particularly helpful for drug dependent clients who may feel chaotic or that they lack boundaries. Feelings are physically held up – “mirrored” – to the client through the image’ (McClean, 1999: 203). Witnessing, such as this process described by McClean, is the act of being an audience to oneself or to others, or to created work within the arts therapies. All these aspects can have an equal importance to the client. Within one session the client can be witnessed by other clients, or by the therapist, and in group therapy can be witness to others. Through empathy the therapeutic work done by others can have an effect on the client. This is true in all group therapy – but the engagement in the arts therapies can be different as the client might be actively role-playing someone in another client’s life, or may be moving with them in a piece initiated by another client, they might be playing improvisational music or be engaged in group painting when another’s mark has an impact on them whilst they are painting elsewhere, or are seeing someone make a mark over their own. There are a series of possible witnessing interactions: • • • •

being witnessed by another group member or/and by the therapist witnessing others, or the therapist clients witnessing themselves either through video, someone playing them in role or movement or music, or being represented by images or objects clients witnessing arts work created by themselves or others.

232 Agents of transformation   Listening in music therapy can be seen to be a part of this process. Aldridge, for example, has written about the therapeutic aspects of listening to others’ work in terms of personal–social interaction. He says that ‘music therapy seems to have an effect on personal relationship, emphasising the positive benefits of active listening’ (Aldridge, 1996: 262). He goes on to look at the possibilities of developmental change being linked to this witnessing. In particular, he explores changes in hand–eye coordination and of non-verbal communication in children with learning difficulties: The active playing of a drum demands that the child listens to the therapist who in turn is listening to, and playing for, her. This act entails the physical co-ordination of a musical intention within the context of a relationship. We would argue that this unity of the cognitive, gestural, emotional and representational is the strength of active music therapy for developmentally challenged children. (Aldridge, 1996: 269) Here, the process of communication is seen, in part, as the development of witnessing between client and therapist. Listening is an act of acknowledging the other, and is seen as an important building block in offering the opportunity for a child to explore relationships differently. The music therapy offers the opportunity for the child to experience being witnessed, and for the witness in them – the listener – to emerge. Listening to, and witnessing, others is cited by Skewes as one of the key aspects of music therapy: ‘the mechanism of change in the music therapy group involves the creation of an attentive, listening and empathic environment . . . this requires the active listening of group members . . . people become more sensitive in their relationships with others’ (Skewes, 2002: 50). Some see the acts of witnessing and being witnessed in a way that is considered as non-judgemental as being inherently therapeutic. Gobey (1996), for example, talks about the exploration of a conflict between boyfriend and girlfriend. A live ‘sculpture’ is made of the situation. People from the group are placed in positions detailing roles, feelings and attitudes of those in a scene. People in the sculpture, and those watching, do not know whether people’s positions represent individuals, or their attitudes and feelings: Those watching are also unaware of the story or characters, although they will quickly pick up which of the figures are in conflict. They are forced to respond to the concentrated emotions of the image and interpret it ‘from within’. In this way the sculpture is allowed to work on several levels: it can be seen as conflict between people in a social relationship or as an inner conflict between different parts of the self. The dispute between boyfriend and girlfriend might



  Triangular relationship to active witness 233 be felt as a family conflict, a political conflict, or an individual’s struggle within themselves. (Gobey, 1996: 29)

The facilitator does not allow judgements of ‘right’ or ‘wrong’ in discussion of the image from people participating and witnessing – the emphasis is on opening the image to the group for associations. If someone sees a mother-and-son conflict, the facilitator does not contradict this but encourages inclusion of varied interpretations. The image might have meaning for each ‘witness’ to explore and also others’ contributions, such as the mother– son comment might open a new meaning for the person who created the sculpture. Gobey makes the important point that witnessing has effects for both those watching and those being watched: No matter how much conflict and disintegration is going on, as long as it is going on ‘on stage’ – with a group of actors relating to each other – those watching have an integrated, and therefore comprehensible experience. The underlying message for all those involved is that conflict can be pictured, can be held, can be understood, without everything falling apart. (Gobey, 1996: 30) Here the notion is that being witnessed by another or others, if it occurs in a situation that can be experienced as supportive, can be important. In addition, the experience for those witnessing in a group context can also be therapeutically important. This importance lies in the fact that the experience is shared and contained. The fear might be that material cannot be expressed or seen without its being rejected, destructive or harmful. The experience of expressed material being witnessed can be one of ‘holding’. This means that the witness, whether this be fellow group members and therapist, or in one-to-one work with the therapist alone, can be a reparative experience or can be the first step in an exploration of material. For those witnessing in a group, or taking part in the sculpture, the act of being with the expressed material can also be important. This importance lies in the way material might connect to their own issues. Work done by one person might be done on behalf of someone else – messages, insight and relevance can connect people’s varied situations. Through empathy someone might be connected to someone else’s work, and this might have a direct effect on their experience of a parallel situation. In addition, the comments of witnesses might be useful and their connections might trigger further explorations. In part, this relates to the process of perspective described earlier – but it is a particular aspect – concerning the process of witnessing or being witnessed. This process is made more vivid by the art processes involved. For the client, the creation of material and expression enables them to witness aspects of themselves or their experience. At the same time, it develops the

234 Agents of transformation   witnessing part of themselves. In active expression the client puts himself or herself forward to be witnessed by another. The active role of the expressive art form is important in allowing the process of exploration of what it is to be witnessed. Feelings such as support or anxiety can be explored through the ways in which the experience of expression through the art form is encountered. In individual or group therapy, however, a key aspect of this process is how the client can shift to discover the value of being an active witness to the dance, movements, images, sound or roles they create: they see themselves and hear themselves. Art therapist Banks draws on the concept of witnessing in her work with a male service user in a low secure unit. She argues that within art therapy a key process can involve how: ‘the patient detaches himself from the external support of the therapist and comes to rely on his own internal secure base, with a less fractured line of self (Holmes, 1993, p. 160). In art therapy it is through the act of ‘witnessing’ the art work from a distance, that the client can see and hear themselves more clearly. The additional experience of art making and talking helps the client to explore the meaning of the art image (Jones, 2005, p. 265). In this way the process of differentiation can be experienced very powerfully in art therapy. (Banks, 2012: 16) She explores this concept in relation to her work with Simon, aged 26, with a complex history which included drug misuse, a non-fatal stabbing of another and a diagnosis of paranoid schizophrenia. He attended both recovery group and individual art therapy at a UK low secure unit for a period of twelve months. He described an image produced in art therapy in the following way: He described the image . . . ‘There’s a feeling of movement in it, which represented the move from prison to hospital. The golden orbs represent the unsettled feeling, where I was not sure of myself. I wanted to make the colours bright and I will draw it again when I get home, it was such a vivid dream, it makes me feel better looking at it really, it just shows you where I was, to where I am now’. He talked about how this image helped him: ‘It helped me by expressing myself through art work. This way you could see what I meant and what I was trying to say. There was something in it, in the art work itself, that shows other people how I feel. I don’t always feel comfortable talking about myself. It was a good thing and it has helped me a lot really’. (Banks, 2012: 22)



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Simon talked about how his experience of art therapy differed from talking alone: ‘I can put my real feelings down, my worries and my hopes which I wouldn’t normally talk about. I draw them down without realising. The more I do it, the more meaning I see in them. The more I look into them, the more I can see my subconscious feelings in them’ (Banks, 2012: 22). Banks argues that the a key ‘continuity’ was sustained for Simon ‘within the pictures and within the relationship with the therapist’ (2012: 23). She concludes that one of the key aspects of the art therapy process for Simon can be understood in relation to witnessing: ‘the process of developing reflective functioning or the witness/viewer through the art image helped Simon to integrate thinking about his violent and offending behaviour’ (2012: 23). In such practice, the witness part of the client is brought to bear upon their life experiences. The role of art within the therapy reflects this, and the products made are witnessed in an active way by their creator. McNiff describes this well when he says: When I perceive the painting that I make, or the dream that I have as other than myself, I set the stage for dialogue. The painting might have something to say to me, and so I take on the role of listener rather than explainer . . . a sense of vitality emerges from these spontaneous expressions, unrestrained by habitual explanations. (McNiff, 1994: 105–6) Here are the links that the active witness function makes – the client sees himself or herself in and through the art form. At the same time, they are offered the opportunity within the arts therapy session to be a witness to themselves, their lives as reflected and processed within the art form and in the therapeutic relationship. In these ways they can be witnessed – by themselves, by others and by the therapist.

Conclusion In looking at the arts therapies as a whole, I would echo the position summarised by Smitskamp: their unique qualities spring from the ways in which ‘they can elicit specifc art-related healing processes, thereby expanding the range of possibilities offered by other psychotherapies’ (1995: 182). Many of the key opportunities that the arts therapies offer concern these potentials: of the relationships between the client, therapist and art form. As the summaries within this chapter have shown, the ways in which this occurs can be described in a series of innovative, connected processes. Of course, dividing up the arts therapies in this way is an artifcial construction around something that, in practice, is not separated into such categories. This was done in order to try to see more clearly the specifc forces combining in

236 Agents of transformation   creating original and exciting opportunities for client and therapist. The descriptions in this chapter have tried to isolate particular aspects of the ways the arts therapies work in order to try to see the whole more clearly, and to identify what makes the differences and innovations in the opportunities the arts therapies offer clients. The arts therapies, as this book shows, have largely developed organically. They did not arrive overnight, nor were they created by one individual. They are the product of many people in many places trying new ideas, exploring new territories and combinations. The arts therapies have emerged through a mixture of discovery, intuition and, later, structured investigation. As we’ve seen, these innovations have emerged as practitioners from different areas and in different countries have challenged what health provision could be. Clarkson has described ‘a characteristic of revolutionary change’ as something that emerges unexpectedly, not ‘out of the regions of probable predictions’ (Clarkson, 1994: 10). Few would have predicted the radical advances made in the past fifty years to the situation described in Part II, where arts therapies are available throughout the world, and where established training, professionalisation and state recognition are becoming commonplace. What would have been seen as highly unlikely a century or so ago is now occurring: the arts therapies are an increasingly recognised presence as a mode of therapeutic change. In talking about scientific revolutions, Kuhn says a common pattern is that: ‘Led by a new paradigm, scientists . . . look in new places. Even more important, during revolutions scientists see new and different things when looking with familiar instruments in places they have looked before . . . familiar objects are seen in a different light and are joined by unfamiliar ones as well’ (Kuhn, 1983: 111). He describes this as a new ‘gestalt’, as elements are put together in ways that are striking, new and offering innovative ways of relating. As an example, he talks about the shift in perception and understanding from the Ptolemaic system that held the moon as a planet rather than a satellite of the earth: ‘In the sciences . . . a perceptual switch accompanies paradigm changes . . . “I used to see a planet, but now I see a satellite” . . . a convert to the new astronomy says, “I once took the moon to be (or saw the moon as) a planet, but I was mistaken”’ (Kuhn, 1983: 111). For those involved in the arts therapies, this recognition may seem familiar. For many the arts have been mainly seen as a diversion, a leisure activity, or a way of making profit from those who wish to consume art, drama, dance or music. The arts therapies, in their emergence, demand a shift in seeing the arts. This change is one that must be made by clients, therapists and health organisations: from local to international levels. It involves a perceptual shift such as Kuhn talks about: from seeing the arts as recreational to seeing them as a force for change, healing or growth. The initial disbelief of a client, or professional, in the face of the idea of the arts therapies; the surprise or shock when, for the first time, the arts touch a client within therapy – these are traces of the shift that is necessary. From planet to satellite: from recreation to therapy. This may appear to be an exaggerated comparison, but, in terms of my encounters with clients in clinical situations, or my own



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experience as a client in art therapy, such a shift can be of enormous significance and have life-changing potential. Smitskamp says that: ‘A creative process can be described as a process in which one liberates oneself from rigid relationships with one’s surroundings, and attempts to form new, original, and meaningful relationships with the world around one by entering into it’ (1989: 33). The rigidities which kept therapy and the arts as separate are breaking, as we have seen. The many new possibilities opened by the connection of the two are covered by the content of this book. The importance now is that the emerged arts therapies should not lose their sense of experimentation, challenge or difference. The new, original and meaningful relationships, described as characteristic of creativity by Smitskamp, must be held onto, as arts therapists work with clients in the various systems of established health provision. The first steps have been made, and are being consolidated: the next must keep the spirit and vigour and risk of the many innovators and initiators described in The Arts Therapies.

PART V

Client–therapist relationship: paradigms, dialogues and disCoveries Budd and sharma . . . rightly acknowledge that the process of healing relies on both parties. the client and the therapist are in a ‘transaction’ together, the client playing an active role in whether change occurs. such a recognition of the ‘added value’ that this can bring is finely expressed by Klein in her comments to clients about their involvement in psychodrama: ‘You already have the problem that you’re presenting. if we go beyond what life has given you, we have a chance to repair it’ (2012: 10). From Chapter 15, page 245 our thought was that combining music therapy and dance/ movement therapy could yield a sum of convergent potentials, based on . . . the obvious connections between music and body-movement and their mutual transactions as arts. therefore, we did not see efficacy as a challenge but as a very plausible output of such an intervention . . . the challenges in terms of efficacy . . . were only related to assuring sufficient evidence of validity that could make of our experimental intervention something . . . replicable and thus useful for others. interview with mateos-moreno and atencia-doña, from Chapter 17, page 325

fifteen

Client and arts therapist: dialogues and diversity Introduction the nature of the relationship between therapist and client within the arts therapies varies enormously. here are some brief vignettes to illustrate this, sometimes bewildering, diversity: a music therapist working with a group of seventeen elderly clients in a residential home compiles songbooks comprising of fifty Cantonese and mandarin songs based on their research into the preferred songs for older Chinese adults. When residents attend sessions they sing along quietly and begin, with encouragement from the therapist, to play instruments the therapist has brought with them. over time participants begin to share songbooks and encourage each other to sing. in between the singing and playing the therapist observes brief conversations in the therapy, and after sessions the clients discuss familiar songs. the therapist notes that this social interaction with other residents was in contrast to the usual behaviour between clients in the home. (Lauw, 2016) a group of refugee youths teach their movement therapist their dances. drumming is involved and is noted as ‘extremely forceful and vigorous’ – to a degree that occasionally meant replacing broken drumsticks. the physical requirements of drumming is such that no one in the group has the stamina needed to drum on his or her own throughout the duration of a session. there is a constant shuttling in and out of drummers, managed by the youths in such a seamless flow that the drumbeat is seldom lost, and the dancing continues without break. the therapist notes that ‘With the drumbeat thickening the air, everyone of both genders would jump up and down in a sustained 240



  Dialogues and diversity 241 rhythmic pattern, traveling a counterclockwise orbit around the drummer’. (Harris, 2007) With no direction from the art therapist a child goes to a doll house that is in the art therapy room and that he has engaged with in the previous session, continuing to barricade the doors to the rooms ‘against the baddies’. he spends most of the session on this activity, discussing with the therapist his strategies for defence and saying that he is trying to ‘protect the children and the animals’. he starts spontaneously to tell the therapist ‘that he had known baddies in his life and that he did not feel safe at home now’. the therapist listens and the client leaves the house, goes to materials that are in the room and paints a bright red star and a gravestone in black on black paper. he then floods the centre of the image with water and says ‘they are drowning and there is no help’. the therapist says that she has noticed the gravestone and that she knew from his mother that his uncle had died: ‘i said that it was natural for people to die, but that we missed them very much when they die. the child adds a lighter gray to the central black paint on the image, and helps the therapist to clear up ‘very carefully’. (Case, 2010) a client tells her drama therapist that she has been sick all week, and is feeling sad and lonely. the therapist invites her to translate her feelings into a landscape and the client describes a desert to her. the therapist asks her to close her eyes, visualise the desert and find out if there’s anything significant there. the client says that there is a woman in her forties in the desert, and begins to describe what she looks like. at this point the therapist suggests that they both move into the ‘playing area’ of the room, which becomes the desert. the therapist invites the client to take on the role of the character and play a fragment of life in the desert. she does so and, playing the woman, rests, meditates, and then gathers some things to make a fire for the night. the therapist takes on the role of an interviewer, who is making a documentary on people who live in the desert. the woman starts to tell the interviewer about her life, how she has left the city and may not return. (Pendzik, 2003)

here are therapists who take on the roles of people from their clients’ imagination, who are taught dances, who create songbooks whilst clients

242 Client–therapist relationship   join in, and who sit with the client whilst they play with a doll house and paint. the differences are mirrored in clients’ experiences as they physically enter imaginary landscapes, dance, paint images, sing and drum. this chapter will examine this diversity, and explore the commonalities and differences within the arts therapies in terms of the ways client and therapist relate. Questions arise from this: do the arts therapies have anything original to say about the client–therapist relationship? do they merely reproduce the relationships present within the existing schools of therapy such as the analytic or developmental? in short, have they come up with anything new? this chapter will consider such questions.

Cultures and contexts authors such as Bondi and Burman (2001) have challenged the terminology and concepts used within the health services to define health and ill-health, and the relationship between practitioner and user. they argue that notions of mental health, for example, are ‘saturated with pathology’. What is ‘normal’ or acceptable ‘mental health’ is unspecified, shrouded in ‘mystery and assumption’ (Bondi and Burman, 2001: 7). such terminology, they argue, betrays the contemporary predominance of a medical model in ways of thinking about well-being and distress, and is accompanied by cultural, historical issues that frame the encounter. What are the implications of these ideas for the arts therapies? this book acknowledges that contact between therapist and client is accompanied by sets of assumptions. We see the attempts by both client and therapist to work across the divide of role and responsibility, within the complexities of communication, experience, privilege, knowledge and power. all of these factors need to be considered, not only in the light of the therapeutic process, but also in terms of creativity and artistic expression. Bondi and Burman help us to see the complexity of each of these areas in defining and encountering the roles of therapist and client. there is a difference between skill, knowledge and power, for example, but these areas often become confused. some argue that at the heart of many health systems lies an inbuilt process which disempowers the patient or client. the healer is positioned as having power, knowledge, skill and is active; the patient does not know, is unwell, is disempowered and passive. sharma argues that there is an inherent contradiction: at the heart of modern medical practice – that between an ethic which declares that the patient’s needs and interests must always be the physician’s priority, and the professional insistence that practice is based on a specific form of knowledge (increasingly technical and scientific) which can only be acquired through training, and is therefore inaccessible to the patient. (Sharma, 1994: 85)



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sharma goes on to say that there can be a tendency for patients who seek collaboration, or to discuss outcomes where ‘medical opinion’ does not admit uncertainty, to be labelled as ‘problematic’. here informed consent, choice and the ways in which roles are seen and carried out, as well as the nature of participation in healing, are key issues. these matters are certainly central for the client–therapist relationship within the arts therapies. some would argue that whilst knowledge and training are crucial, they do not necessarily lead to the disenfranchisement of the client. others are of the opinion that the arts therapies encourage the patient to be active and creative, that the participatory act is experienced in such a way that the client is empowered. some review their practice to examine issues of power which manifest themselves in counter-therapeutic ways. Whilst others would argue that issues around power are inevitable, but can provide a useful feature to explore within the therapeutic relationship (Jones, 2007; sajnani, 2016). different schools of therapy approach this in a variety of ways – the cognitive approach stressing the need to establish collaboration and alliance, the analytic exploring issues through transference and counter-transference, for example. douglas places similar issues in an intercultural context. she considers health in the context of collaboration and rejection, notions of illness or disease affording powerful weapons for ‘self interested blaming and excluding’ in any society (douglas, 1994: 33). she says that communities always involve judgement and persuasion: ‘the fragile human body is the political touchstone, and blame is the justification for exclusion’. she asks questions across cultures: if the punjabi patient has a sinking heart, what does he expect his community to do about it? if the lele with pneumonia suffers from crossed-over ribs, what can be done to uncross them? in either case what was the cause of the ailment? Who is to blame? the patient? or the doctor? or the mother-in-law? (Douglas, 1994: 33) her argument is that it is necessary to know what she calls the whole scenario: ‘to describe diagnoses as if they were museum items is of no interest. We need a holistic context. according to what kind of blaming is going on, the role of the therapist will be differently constructed: to avert the finger of blame, to point it or attract it’ (douglas, 1994: 33). she says that the more highly organised the society, the more intense the accusing and blame becomes. she argues that the experience of ill-health in industrialised societies, for example, involves the tendency to draw individuals out of their normal context. the ties of ‘loyalty’ and ‘support’ can become removed and individuals are stranded as what she calls ‘isolates’ (douglas, 1994: 40). helman (1994: 280) has said that when therapist and client come from similar backgrounds they are more likely to share assumptions about the

244 Client–therapist relationship  origin, nature and treatment of psychological disorders. however, if this is not the case then clients: may have to learn this world view gradually, acquiring with each session a further understanding of the concepts, symbols and vocabulary that comprise it. this can be seen as a form of ‘acculturation’, whereby they acquire a new mythic world couched, for example, in terms of the Freudian, Jungian, Kleinian or laingian models. (Helman, 1994: 280) here a criticism concerns the power imbalance within much healthcare, which often means that the patient must accommodate the world view of the therapist. Clarkson and nippoda have echoed these perceptions in a way that can help understand how the arts therapies can address these matters and how ‘change’ is positioned. they say that each therapeutic relationship occurs within the idiom and atmosphere, the climate and background of the cultures which ‘impinge on it’ (Clarkson and nippoda, 1998: 96). they define cultures as structures of feeling and list these relating to gender, religion, organisation, profession, sexual orientation, class, nationality, country of origin, and in some contexts, ancestral origin. they note the variety of attitudes towards therapy relating to areas such as class and ethnicity, for example. these factors can lead to attitudes such as ‘it [being] experienced as a stigma to benefit from therapy services’ (Clarkson and nippoda, 1998: 97). they also acknowledge that many more people in the world rely on ‘symbolic healing or culturally traditional approaches to personal development than on West european models’ (Clarkson and nippoda, 1998: 97). these comments connect to the need for the arts therapist to be aware of how traditions and attitudes concerning health, change, culture and the arts relate to the ways in which political and cultural contexts connect to the arts therapy relationship between client and therapist. one such debate concerns what is referred to as the ‘medical’ or ‘social’ model of health. this has emerged as people with disabilities, for example, have challenged a perspective on health provision that positioned them in terms of deficits and medical diagnoses or labels, rather than looking at the broader social, cultural and political context of themselves and their lives (pavlicevic et al., 2014).

Client–therapist transaction Budd and sharma have said that the ‘healing bond’ relies on the assumption that the healer or therapist has something to offer which can make a difference. this can involve a ‘remedy’, or providing the conditions and resources for the client to heal themselves. they assert that healers are not neutral; they have views about the client’s condition, the nature of the



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healing process, what kind of outcome may be expected and what the limitations of the process might be (Budd and sharma, 1994: 17, 102). Budd and sharma also rightly acknowledge that the process of healing relies on both parties. the client and the therapist are in a ‘transaction’ together: the client playing an active role in whether change occurs. such a recognition of the ‘added value’ that this can bring is fnely expressed by Klein in her comments to clients about their involvement in psychodrama: ‘You already have the problem that you’re presenting. if we go beyond what life has given you, we have a chance to repair it’ (2012: 10). this framework is an interesting one to use to explore the nature of the relationships between client and therapist in the arts therapies. a transaction occurs – involving opinions, opportunities, limitations, choices, actions and exchanges. arts therapists such as hogan (1997) have explored aspects of this interaction, for example concerning the social construction of illness. so, how do these areas relate to the arts therapies? how do arts therapists act? What part does the client play? how do arts therapists view the conditions their clients bring to the therapy? What role does their relationship play within the outcomes and limitations of the arts therapies? how adaptable are the arts therapies? how responsive are they to the individual therapist and client and the variety of their lived contexts? the notion of context underlies all these questions. examining research from different countries and within, and between, different cultures there can be said to be some consistencies. most, for example, feature the concept of a triangular relationship between therapist, client and art form (see Chapter 14). however, some argue that whilst there can be parallels, contextual interpretation or dialogue is crucial to the therapeutic relationship in the arts therapies. rolvsjord and stige consider client and therapist in this light: the experiences as well as the outcomes of music therapy are related to broader social, cultural, and political contexts. With this . . . level of awareness, we point toward music therapy processes where activities are interlinked with and operate in interaction with a broader ecology of contexts, such as the local community of the client and therapist, the institutional context, the musical culture, the health-care politics. (Rolvsjord and Stige, 2015: 18) here they situate the arts therapy relationship as an active part of a web of contexts that affect both the ‘experience’ of each therapy session as well as broader ‘outcome’ or effect of the practice. orr parallels these concerns in her interview with therapist ndiaye at the hôpital aristide la dantec in senegal, who argues that in a senegalese context: For art to be therapeutic, there are two things. one is the fact that it’s a way for them to ventilate and project

246 Client–therapist relationship  something and take some space, and i think there has to be some purpose. there has to be a plan and there has to be some kind of debriefing of what’s been produced. it could be something like following the evolution of what the patient has made . . . some sense has to be made out of what they are doing. (Ndiaye, in Orr, 2016: 34) orr goes on to add to ndiaye’s views in ways that conceptually positions the relationship between the client and arts therapist as consisting of interconnected values, processes and methods: additionally, for art to be therapeutic, it has to fit within the patient’s cultural context. this is true for each culture; there cannot be one standardized method for doing art therapy – or therapy in general for that matter. on the contrary, in order for it to be effective, it must be presented in a way that the patient can understand, a way that is culturally relevant to the patient. in the senegalese context, art therapy incorporates cultural values and aspects that are important to the society. in this way, the patient can relate with and recognize its process and methods, thus allowing them to easier connect with it and have a higher chance of being healed. it also gives the patient confidence that they can create something, make something from start to finish. (Orr, 2016: 34) is there a way of understanding the nature of this relationship across these different cultures? is the relationship between therapist and client the same in turkey as it is in uganda? is the relationship between an adolescent client and their therapist in the Bronx the same as that between an elderly client and their therapist in taiwan? here a host of other questions regarding difference and similarity arise – concerning race, culture, gender, class, age and sexuality. of course, these are questions that every form of health practice needs to address. however, in the arts therapies there are particular complexities, concerning culture and context – relating to areas such as the art form and artistic expression. as we have seen in parts ii and iii, cultural attitudes towards the arts play an important part in forming the nature of the contact between arts therapist and client. this chapter will explore these themes within arts therapies practice. as already noted, the arts therapies have evolved to offer a great diversity in the ways in which the client–therapist relationship can be created. an important element in this diversity of relationships is in response to the wide variety of clients who make use of the arts therapies. as part ii showed, the arts therapies work diversely with, for example, clients with learning difficulties, as well as with clients with schizophrenia; they work with families,



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groups or with individuals. this, then, can be seen as a transaction: the ways the arts therapies have developed and are developing in response to the contexts, demands and needs of clients. the next section will begin to examine a key aspect of this transaction: the different roles within the therapeutic relationship.

Roles of the arts therapist the arts therapist combines different roles within the transaction between client and therapist. this can be said of any therapist, but for the arts therapist there is a unique combination of traditions and roles. i will argue that this mixture creates an innovative relationship between therapist and client. as pointed out above, arts therapists practise within a wide range of therapeutic frameworks or paradigms. these all affect the ways in which the therapist conducts herself or himself, the way in which they understand the difficulties and potentials which bring the client to therapy, and the ways they relate to clients. the arts therapist has evolved from artist, therapist, arts teacher and, in some contexts, traditional healer and shaman – this is a historical reality, as shown in Chapters 8, 9 and 10. For the practising therapist, i would argue, this ‘role history’ is present in their everyday relationship with their clients. the presence of the therapist and their relationship with their clients contains these different roles. the relationships between these roles is a dynamic one. it varies within different frameworks of practice, and it varies during the life of any therapeutic contact: from within a single session to the whole extent, or time of the therapy. this dynamic provides a way of understanding the special opportunities that the arts therapies offer the client in their ways of working. i am going to use it to explore the client–therapist relationship in the arts therapies. this chapter along with the next will explore this role dyad: therapist and artist. they will look at each of the roles, but also at the ways in which the sum of the dyad is more than its parts. specifically, this chapter will look at the ‘therapist’ element of the arts therapist’s identity and will consider this aspect of their role.

Therapist and client the task of the arts therapist is to provide an opportunity for change to occur for the client. most would recognise Clarkson’s defnition of the therapist as someone who ‘can only point the way, facilitate the journey, but in the end cannot do it for the client. the client has to do it for himself’ (Clarkson, 2002a: 283). the ways in which this happens varies widely across the arts therapies. looked at historically, by the late twentieth century the arts therapies had developed as independent disciplines, as described earlier. however, they

248 Client–therapist relationship  emerged in dialogue with a variety of therapeutic frameworks, as we have seen in many of the illustrative examples so far. often, the arts therapies have allied themselves, or become related, to specific schools of therapy, which have developed alongside the arts therapies. sometimes, as part ii showed, the very titles of the arts therapies indicate this. art therapy, in particular, reflects alliances through a variety of names. as well as ‘art therapy’, other alternatives are used such as ‘analytic art therapy’ or ‘art psychotherapy’, for example. these reflect the allegiance between art therapy and the practice of analysis or psychotherapy, respectively. other theorists have argued for what they call a more ‘independent’ way of thinking – that the arts therapies have their own framework concerning change and the client–therapist relationship. this way of thinking tends to reduce allegiances with other schools of therapy, and looks towards ways of understanding the nature of change in the arts therapy as unique. this approach tends to try not to use other frameworks to help describe or understand the way the therapy is effective. this chapter will look at these different frameworks in terms of ‘dialogue’ concerning the nature of the therapist and client relationship. it will use as illustrative examples the analytic, cognitive behavioural, developmental and mindfulness traditions. in addition, it will look at what is different or unique about the client–therapist relationship in the arts therapies. the following gives a very brief summary of the main relevant features of the paradigms or schools of therapy which have been frequently involved in such dialogue with the arts therapies. Within the analytic framework the emphasis is upon the nature of the client–therapist relationship and the way in which the client makes use of this within the therapy. Conceptual ideas such as transference and counter-transference, projection and introjection are used within this approach to make sense of how therapeutic change occurs. the therapist encourages the client to use the relationship between them within the therapy, and the therapist may make use of strategies such as interpretation. Within the cognitive behavioural approach the therapist and client work together in an alliance. the therapist enables the client to formulate therapeutic goals and together they work to achieve those ends. the therapist encourages the client to reflect and discuss the ways in which they can achieve changes in the way they function and relate, looking to set manageable goals and then to review the process of change as it develops. the humanistic therapist emphasises the ‘in the moment’ experience of the relationship between therapist and client. the therapist will draw the client’s attention to difficulties or issues that arise within this, and emphasise the creation of empathy and genuineness. stress is placed on the idea that there is an innate drive towards growth within each human being and that the therapist aims to enable this: ‘the human



  Dialogues and diversity 249 organism is . . . active, not passive. For instance, inhibition of certain behaviours is not merely absence of these behaviours . . . an active holding in. if the inhibition is lifted, what was being held in does not then passively emerge. rather the person actively, eagerly brings it forth’ (in perls et al., 1951/89: 22, quoted in Clarkson, 1994). the developmental perspective sees the client’s position in terms of a block or halt in development. assessment looks at the client in relation to a developmental sequence, and attempts to identify where the difficulty or halt has occurred. this is followed by the developmental process being revisited within the therapy in order to renegotiate the stage, or stoppage, with the therapist as companion or guide (read Johnson, 1982). drama and play therapist Cattanach summarises the approach in relation to developmental psychology which uses ‘the concept of living in time as a way to understand human development. their exploration is of life stages and the mechanisms and processes of human development. individual theorists put forward developmental schemes which emphasise a variety of aspects of the self’ (Cattanach, 1994: 31). Mindfulness combines traditions based in Buddhist philosophy and practices, often linked to meditation, and health contexts. it has been summarised as involving individuals attending to the present moment. shapero et al. (2018) have described mindfulness as having two main components. one concerns ‘self-attention’ to the experience of the lived moment and the other involves adopting an openness and acceptance toward one’s life experiences. therapeutic approaches drawing on this tend to help clients develop mindfulness ‘skills’ in order to increase this kind of ‘attention’ and to develop a different relationship with their thoughts. this might, for example, involve practising different strategies in relation to distressing thinking patterns and emotions: through activities and exercises, clients develop their capacities to step back or disengage from ‘initial thoughts by creating a meta-awareness (i.e., awareness of being aware)’ (2018: 32).

these differences matter, as they affect how the client is understood, and the ways in which they work within the therapy space and with the therapy methods. Where there is choice, the client might select a particular therapeutic approach. Where referral is the procedure, then the question of how best any paradigm will suit the needs and demands of the client must be a feature in considering the selection of a framework. however, as i will show, the arts therapies have not simply taken the approaches described above, and transferred them wholesale into their theory and practice. their relationship is more dialogic than that, as the next section will show. the following examples sample some of the frameworks in the above summary to illustrate and examine these relationships.

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Arts therapy relationships: dialogue and discovery i will argue that two main things are occurring. one is that the arts therapies have evolved in dialogue with other models of therapeutic relationship, and also with other disciplines such as teaching, or arts practice. the second is that the arts therapies have made unique discoveries about the relationship between client and therapist. there are numerous examples of the way dialogue has occurred between the arts therapies and other therapies. Bunt, for example, points out that there was a tradition in the usa during the 1960s and 1970s of music therapists developing a view of music therapy as a form of behavioural science (Bunt, 1997: 256). here music therapy developed a dialogue with behavioural therapy. the root of the idea is that certain activities can be encouraged and reinforced by rewarding the client, so that action and reward are associated. listening to music was evaluated as a reward, for example. studies looked at music’s role in the reduction of aggressive, stereotyped behaviour, or in the development of concentration or reading skills. the next sections form a detailed sample of the dialogue between the arts therapies and three different therapeutic frameworks. they show how the art therapies find a variety of ways in which the relationship between client and therapist feature in therapeutic change.

Arts therapists and clients Dialogue with analytic psychotherapy the frst example is from us dance movement therapist dosamantesBeaudry (2007). she situates her individual private work with elizabeth within a psychoanalytic framework, speaking of a ‘signifcant paradigm shift’ in the feld, ‘moving from single mind, internally-driven theories of self development to relational, two person and systems’ theories that stress the ‘social, co-constructed nature of mental life and relationships’ (2007: 74). her further description of the ‘paradigm’ she works within emphasises many of the areas described earlier as being connected to an analytic framework, in terms of the interaction between therapist and client, noting that ‘the view of the analyst as a blank screen upon which the patient projects feelings and wishes has shifted over time to that of two co-participants involved in a process of discovery and co-construction’ and that this is centred upon the evolving ‘patient’s sense of self and self narrative’ (2007: 74).

Elizabeth: aims of the dance movement therapy dosamantes-Beaudry sees dance movement therapy as connected to intersubjectivity. she draws on stern’s (2005) defnition of this as being the capacity to share, know, understand, empathise with and to ‘participate and enter into the lived subjective experience of another’ (2007: 74). she sees the aim of



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her work with elizabeth in terms of ‘a psychotherapeutic approach’, where the therapist ‘tracks’ her own and the patient’s ‘nonverbal (somatic sensory, movement and imagistic experience)’ to ‘understand’ the client’s ‘shifting self states and intersubjective relationships being constellated during the course of the treatment process’ (2007: 74). she relates this to particular client contexts, for example elizabeth’s experience is seen as parallel to individuals who ‘suffered early self derailments and who during their treatment spontaneously regress to preverbal self states that they originally found to be too diffcult to bear and were unable to integrate into their sense of self’ (2007: 74). the dance movement therapy is seen as a safe environment to assist in elizabeth’s exploration, initially connected to regression and non-verbal exploration through movement and her relationship with the therapist.

Elizabeth: method and the client–therapist relationship the method used in the therapy is dance movement improvisation. dosamantes-Beaudry defnes the central agents of change as the client–therapist relationship and movement. she orients her thinking and practice, not solely in terms of dance movement therapy theory and aims, but by drawing parallels and distinctions between psychoanalysis and dance movement therapy (2007: 80). the therapist’s role is seen by dosamantes-Beaudry as being to understand, refect and interpret – either in movement or verbally – therapeutic issues that have particular relevance for the client. she sees movement in terms of forming a relationship of ‘dialogue’ between therapist and client. areas such as the pattern of shared movement or verbal and ‘embodied dialogue’, are positioned in relation to client change. For some clients, such as elizabeth, the boundaries and nature of the therapeutic relationship can provide safety to express and, eventually, to make unavailable memories conscious. once this has been communicated, links between behaviour and feelings may be explored. the role of the therapist is defned in this situation as chiefy being to witness, observe, think and respond: for example, to ‘consider the sensations and images that preverbally regressed patients derive from their own bodily-felt experience to be transitional objects whose psychodynamic meaning remains to be discovered by the patient within the context of the evolving intersubjective therapeutic relationship being jointly created by us’ (2007: 80). dosamantes-Beaudry talks about how, over time, trust develops and issues of transference and countertransference are referred to by her: the client unconsciously bringing other relationships to their contact with the therapist as symbolic expression. such relationships with the therapist are expressed in the use of space and body, and are presented by dosamantes-Beaudry as both an expression of the client’s distress, and also as the means to its resolution. as the case example below will show, the therapist sees the client’s use of dance movement and the relationship through dance movement with the therapist in the light of a reparative relationship. initially the client, elizabeth, is described as spending several weeks lying quietly on the foor, with the therapist sitting quietly on the foor at some distance.

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Case example analysis Case example: Elizabeth after some time elapsed elizabeth began to risk sharing and moving some of her emergent visual imagery with me. . . . one day she shared the following dream with me. her mother had given her ‘a beautiful gift, a diamond necklace’ but ‘instead of appreciating it and loving it (she) dreaded receiving it and (she) experienced it as harmful.’ as she interacted through receptive movement with the necklace of her dream, she discovered that it was a ‘beautiful diamond choker.’ as she proceeded to place the diamond choker around her neck, she began to choke and found herself desperately gasping for air and for her life, unable to breathe. . . . as she laid on the foor and gasped for air i experienced my chest tighten . . . When i asked elizabeth whether there was anything she could do to ease the pressure that the necklace was exerting, she gasped and replied ‘no’ that she ‘felt totally helpless.’ as she struggled to breathe, however, she suddenly discovered that by releasing the clasp on the back of the diamond choker, she could breathe freely again. (in that instant, elizabeth discovered for herself her own sense of agency and power as an adult.) in therapy, elizabeth re-enacted her deep sense of maternal abandonment and deprivation by becoming ill with a cold just prior to my first vacation leave. When i returned, she initially regressed to her previous self encapsulated state for a period of time and then became verbally enraged over what she considered to be my ‘abandonment’ of her. i listened quietly to her as she railed against me and imagined her as a toddler having an explosive temper tantrum because her mother had left her alone to fend for herself. When she calmed down and was able to hear me, i pointed out that there might be a connection between her present experience of abandonment with me and her earlier experience of maternal abandonment by her mother. the therapeutic relationship had survived a potential major rupture. our transcendence of this critical emotional storm, allowed elizabeth to continue to experience the therapeutic relationship as a caring ambiance that could still be ‘soothing’ and useful to her. she remarked that the therapeutic relationship ‘was not like the one she had had with her mother’ but stood in sharp contrast to it. i noticed that the affective tone of our relationship had shifted from a very stormy, rageful one to a more pacific and soothing one. (dosamantes-Beaudry, 2007: 81–3)

here the therapist and client use the dance movement within the therapy as a way of exploring how behaviour, thinking and feeling within the sessions are influenced by the unconscious. through dialogue, the embodiment



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and interaction with the imaginary necklace, for example, dosamantesBeaudry is a witness to the client’s expressions. the relationship with the therapist evolves through improvisation and the symbolic use of movement. as implicit material is made explicit through movement, it can be worked with to create change. the therapist, through witnessing, listening, responding and interpreting, supports the client to express and resolve the issues they bring. an example of this is the therapist’s intervention when elizabeth experiences choking: she asks if there is anything elizabeth can do to relieve the pressure. the client’s subsequent physical response is interpreted as ‘elizabeth discovered for herself her own sense of agency and power as an adult’ (2007: 83). this is framed, in part, by the notion of a reparative relationship. the therapist makes reflections and interpretations enabling the client to engage with cut-off, or repressed, material, for example in her comments: ‘i pointed out that there might be a connection between her present experience of abandonment with me and her earlier experience of maternal abandonment by her mother.’ the client is enabled to explore the ways in which the dance movement and the relationship with the therapist reflect such material. she can then consider the situation, and explore new possibilities, framed as: ‘to redress aspects of her maternal relationship that had affected her capacity to establish a coherent, integrated and empathic sense of self’ (2007: 87). read Johnson (1998) has summarised what he has described as a psychodynamic model of the arts therapies as containing three main components: projection, transformation and internalisation. in projection, connected to the concept explored in Chapter 14, aspects of the self are expressed in artistic products and processes. Transformation is the process through which personal material formed in artistic expression is ‘altered, worked through or mediated’ (read Johnson, 1998: 85). he acknowledges a debate within the arts therapies as to whether this transformative element is one that occurs ‘naturally’ as the result of the arts medium, or is dependent on the therapist’s intervention. Internalisation concerns the way in which the transformed material is ‘reintegrated’ into the client’s psychological state. aspects of these three processes can be seen in the case example of elizabeth. this concerns the use of embodiment in the way elizabeth physically expresses herself and her relationship with the therapist: for example, in the ‘laying quietly on the floor while attending to her own emergent bodilyfelt sensations’. the arts form and the relationship are co-present as the therapist makes use of her own bodily sensations whilst in the space and experience of elizabeth’s movement: ‘as she laid on the floor and gasped for air i experienced my chest tighten’: the therapist makes comments that indicate she empathises with the physical experiences of choking and suggests a way forward, rather than leaving the client to experience choking alone. this is interpreted as redressing early experiences, ‘to redress aspects of her maternal relationship that had affected her capacity to establish a coherent, integrated and empathic sense of self (2007: 85). Central to this approach, then, are the ways in which movement processes in the context of a therapeutic relationship engage with material related to the client’s

254 Client–therapist relationship  unconscious. the emphasis in read Johnson’s account is on the role of the arts process within this. as shown in the situation with elizabeth, the relationship between therapist, client and arts process is an important aspect of how change occurs. this focuses on the ways in which the arts products and processes are part of the relationship with the therapist understood in dialogue with psychoanalytic concepts.

A psychoanalytic framework and the arts therapies: critiques and limitations our internal worlds and our psychic realities are our selves. selfhood is deeply influenced by other people. much of the self is seen as constituted from internal representations of other people and relationships – whole people, aspects of people and . . . the ways they relate to us, and to each other. (Stevens and Wetherell, 1996: 285) some have criticised this way of viewing the self, as being too rooted in a particular way of dealing with identity and client problems, and this limits its usefulness. holland, for example, has said that Freud and Freudian thought are readily identifed as products of late nineteenth-century european society: ‘a period in which family life was relatively autonomous and thus of considerable importance in psychic development. With the decline of the nuclear family’s autonomy in our own, very different late-twentieth-century society, however, the continuing relevance of orthodox psychoanalysis is far less readily apparent’ (holland, 1988: 405). in relation to transcultural counselling, d’ardenne and mahtani (1989) describe transference as the attitudes and feelings placed by the client on to the counsellor or therapist. there is an additional dimension – clients who have had a lifetime of cultural and racial prejudice will bring the scars of these experiences to the relationship. interpretation is used in the case example. the therapist, within this framework, can make suggestions as interventions. however, this needs to be done with sensitivity and an awareness of power issues in the client– therapist relationship, and the differences of cultural awareness and language as discussed by d’ardenne and mahtani (1989). it’s not as if all practitioners within an analytic framework will directly connect with the approach taken here by dosamantes-Beaudry – as within the analytic field itself, there are a diversity of emphases and approaches such as Jungian, Kleinian or lacanian. Jung, for example, speaks of the goals of psychotherapy as involving the therapist being guided by the patient’s own irrationalities. he says that ‘we must follow nature as a guide, and what the doctor then does is less a question of treatment than of developing the creative possibilities latent in the patient himself’ (Jung, 1931: 88). a number of arts therapists have pointed out that it is important that the arts aspect of the process is not seen only as a way of realising analytic processes within the therapy. skaife, for example, has pointed to the danger of a tendency in ‘art therapy groups run along group analytic lines’ (skaife,



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2000: 116) for the art work to be regarded primarily as a reflection of the group process, of the relationships in the group. she says it is important for the aesthetic aspects of making art, which parallel the interactions between self and the world, for example, to be paid attention to in the conversation between arts and therapy. in dosamantes-Beaudry’s work we can see an illustration of this approach: how the arts form is an integral part of the dialogue. the next case example illustrates another of the dialogues, this time with a developmental approach to therapy.

Dialogue with a developmental approach to therapy Sophie: method and the client–therapist relationship aldridge (1996) describes his approach as being related to music therapy as developed by nordoff robbins. this is typifed as the therapist’s being in the role of ‘encourager’: to encourage the client to improvise using percussion and tuned percussive instruments; to sing with the patient; and to encourage the client to play with the therapist at the piano (aldridge, 1996: 9). he specifes that there is no attempt to interpret the music psychotherapeutically. the vehicle for therapy is the development of a musical relationship between therapist and client within the creativity of improvisation.

Sophie: aims of the music therapy the case example below is from work with children referred to by aldridge as being ‘developmentally delayed’. in describing the issues brought to therapy aldridge frames the children’s situation in developmental terms. the concerns for the child, sophie, in the case example relate to the acquisition of speech and meaningful communication. music therapy is seen as a way of encouraging children without language, or who are experiencing a developmental delay, to communicate. such developmental delay can be seen in terms of emotional confict, the experience of rejection or behavioural disturbance. aldridge focuses upon the area that relates to the client’s situation or context, and on communication: ‘our therapeutic task is to respond to abilities and potentials so that those limitations themselves are minimised. if both environment and the individual are important for developmental change, the therapist provides, albeit temporarily, an environment in which individual change can occur’ (aldridge, 1996: 245). he sees this as an ‘ecological’ way of understanding the child. this places the client in a context, in terms of relationship, identifying the diffculty in terms of interaction with others, and the development of communication. this is at ‘the heart’ of the music therapy’s approach: when referring to development he is ‘speaking about the ability to communicate either non-verbally or verbally’ (aldridge, 1996: 268).

256 Client–therapist relationship  the focus in this framework is upon the ways in which communication is dependent upon motor activities and responses. these are seen as ways of also indicating that a child is developing. Communication is seen to be dependent upon ‘doing’ and this, in conjunction with relating to another person, is central to the working hypothesis. aldridge sees the locus of music therapy here as being a non-verbal therapy that enables the establishment of a communicative relationship before ‘complexities of lexical’, or verbal, meaning are necessary (aldridge, 1996: 248). the emphasis is seen to be on the development of the inherent potentials of the client rather than on ‘known pathologies’. he draws a clear boundary with a behavioural approach which would have set specific goals for developmental change, as this would not have aimed to elicit potential in the same way, and would have detracted from the client and therapist’s making music together. the music therapy aims to ‘foster’ this potential, creating opportunities for the development of purposive coordinated change in a context of time and relationship. aldridge uses the term ‘dialogue’ and sees the importance of the therapeutic relationship as a ‘joint activity’. he sees the therapist and client in parity. the therapist and client alike have joint responsibility – both in creating improvisations and for continuing them.

Case example: Sophie aldridge saw sophie in individual sessions over a three-month period. she was part of a group also receiving treatment, all of whom were between 4 and 6.5 years old with a ‘developmental age of 1.5 to 3.5 years’, with no previous experience of music therapy. the framework involved an initial assessment based on psychological and functional criteria, and used the nordoff–robbins and griffiths scales. these are framing ideas within the therapy, as they inform the criteria chosen to understand therapeutic change. the griffiths scale, for example, is based on the observation of small children, and concerns itself with gaining insight into areas of learning. the idea is to provide ‘a profile of capabilities from which the child might respond’ (aldridge, 1996: 255). it looks at areas such as locomotor development – whether the child pushes with feet, lifts their head, kicks vigorously or can catch a ball. other areas include ‘personal–social criteria’ – whether the child responds to being held, makes anticipatory movements, plays with others, whether they can make vocalisations other than crying, searches for sound visually, or appears to listen to music. in nordoff–robbins, the other scale used, one assessment area is described as ‘Child–therapist relationship in musical activity’. this sees the work totally in terms of observable actions, such as participation in activities, mutuality in the expressive mobility of the



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music, whether there are ‘assertive co-activity and signs of awareness’ (aldridge, 1996: 252–3). another area ‘musical Communicativeness’, sees therapy in terms of levels of communicativeness described as a series of criteria – such as commitment, enthusiasm, musical competence, attentive responsiveness and evoked responses in musical form (aldridge, 1996: 254). again the emphasis is upon physical observation – of the client’s use of instruments, vocal expression or body movement. the notion here is of a developmental process. initially the therapist assesses the relationship between therapist and client: whether, for example, there seems to be total obliviousness, limited response, or a stability and mutuality of playing music together. another frame uses the notion of no communicative response, active participation or ‘intelligent musical commitment’ (aldridge, 1996: 259). during the music therapy the relationship is seen and developed through the musical activity. in nordoff–robbins a correlation is drawn between the personality development of a child and the character and consistency of the musical communicativeness they show (nordoff and robbins, 1977: 193, in aldridge, 1996: 259). in the case history of sophie, this framework is reflected in the way aldridge conducts and reports the therapy. she is introduced in terms of physical and social development. she is reported as muchwanted by her mother. sophie could sit at four months, but did not develop crawling and pulling up to stand, though there seemed to be no organic cause. she could hear but not use speech; she played alone. the first session is reported in terms of sophie’s relationships – she clings to her mother, and is physically carried into the room by a cotherapist, remaining on the co-therapist’s arm during the session. she seems to show signs of anxiety, whimpers and plays a small bell and chime bar so quietly aldridge can hardly hear them. the therapeutic process is described in terms of a variety of developmental changes. so, for example, aldridge comments that sophie by the fourth session enters the room alone. she initially goes to a piano and plays single unrelated notes; she sits in the co-therapist’s lap and plays drum and cymbal. aldridge plays on the piano at the same time as sophie improvises. her notes are ‘accidentally met by the therapist . . . [she] was very insecure in the musical pauses and immediately retreated from rhythmical impulses’ (aldridge, 1996: 266). she goes on to play more often ‘in relationship to the music’ (aldridge, 1996: 266), using both hands in drumming in parallel and in alternation. she is described as being more ‘sure in the therapeutic relationship’, and makes more ‘effort’ to play. she is described as becoming happy, expectant and playing with more security. in the eighth session aldridge describes a ‘significant change’ concerning her being constantly active, her musical playing being more

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recognisable. sophie accompanies him, decides between loud and soft, repeats musical motifs, and she can focus without being distracted. aldridge is described as supporting her accidental changes in the music into becoming part of a ‘musical whole’; sophie ‘worked hard’ to maintain the musical relationship. By the final session she is described as having the capacity to use many developed, musical improvisational possibilities. through processes of internal monitoring, using the scales described earlier, and through feedback from sophie’s mother, change is noted in terms of factors such as listening, or hand-and-eye coordination. other observable areas are used, such as playing with others, independent activity and independence in communication, sophie’s capacity to relate to toys, and her initiative in establishing communication, or movement and locomotion: ‘that sophie could show both sadness and happiness was considered to be important for her mother. that she could also cuddle was a significant milestone in the emotional relationship of child and mother’ (aldridge, 1996: 268).

Case example analysis aldridge frames this therapeutic change as connecting to music therapy’s capacity to facilitate development, and to enhance it for those whose development is ‘impaired’. other arts therapists (Cattanach, 1994; Ferrara, 1991) have described how, as Ferrara says in the context of art therapy, art can be a vehicle for development and a reflection of a child’s cognitive and emotional growth. art also may provide the opportunity for growth in intellectual, social and aesthetic areas. as an expressive communicative channel, art may embrace creativity, self-expression and manipulation of the environment. therefore art contributes to overall development by providing the conduit for responding to experience and expressing the change that occurs at every developmental stage. (Ferrara, 1991: 44) Ferrara points out that art can ‘reconstruct’ elements of personality attenuated by developmental processes, quoting Williams and Wood’s view of art as an opportunity for ‘new learning where a gap has existed. it is a means for venturing into the next, new steps’ (Williams and Wood, 1977: vii). aldridge and Ferrara both relate their practice to literature which refers to human development in a framework of areas such as non-verbal



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communication, gesture and emotional expression and in cognitive development (merlin, 1993; alibali and goldin-meadow, 1993). here cognitive, gestural, emotional and relational development are brought together. the therapist and client relationship is seen as valuable as it involves playing together, the therapist and child together developing new possibilities. For aldridge, the musical relationship is seen as a ‘domain’ – a ‘zone’. the emphasis is on creativity, listening and playing in this area. the therapist responds to the child, the child to the therapist: this is a ‘mutual realm’. through contact with the therapist and music, the child becomes open to variety, and variety leads to development. the relationship created through making music together enables action along with developmental and cognitive change. the emphasis is on music as being non-verbal and not language-dependent. this is seen as especially important for clients such as sophie – developmentally delayed infants. the underlying concept within this paradigm is neatly summed up by art therapist Ferrara when she refers to the ‘dynamic interdependence of physical growth, intellectual and emotional development, and creativity’ (Ferrara, 1991: 50). the therapist and client work together to identify problems in terms of a developmental framework. they go on to use the connections which the artistic process has with opportunities to negotiate, renegotiate or achieve the developmental work which has not yet occurred, but which is needed.

Developmental approach and the arts therapies: critiques and limitations some arts therapists have pointed out the importance of issues concerning race and culture in terms of developmental assumptions. if, for example, the therapist and client are from different cultural or racial backgrounds, with different models or assumptions of development, this can result in problems within the therapy. importance is placed on the therapist and client being conscious of power relations, of majority–minority issues in relation to culture, and to difference, as well as the way in which artistic expression and products relate to such areas. Barber and Campbell (1999) in their discussion of ‘colour and identity’ raise issues that concern difference and power: ‘the art therapy process allows images of the self to be created and recreated in as many ways as is necessary for the person to tell her story of who she is and how she comes to be how she is’ (Barber and Campbell, 1999: 31). this is relevant to developmental thinking. they advocate the ‘narrative’ and ‘coconstruction’ mode of therapy. they mention, in particular, the notion of the way in which meaning needs to be constructed in dialogue – not something held by the therapist alone. in, for example, a mixed race art therapy group ‘the images and dialogues which are created allow for the generation of new and multiple meanings of being black, or white, or brown’ (Barber and Campbell, 1999: 34). they go on to echo some of the areas described by Cattanach and read Johnson as concerning the

260 Client–therapist relationship  developmental approach to self, development and time: ‘there is not one truth but rather multiple meanings born of subjective, lived experiences. this is very important to the image-making process in mixed groups, for in any one image a person can convey experiences of self across time and space, both internal and external’ (Barber and Campbell, 1999: 34). here there is no such thing as an ‘objective viewpoint’; people are not studied or understood in terms of object and subject ‘uncontaminated’ by the viewer’s viewpoint, or the context in which the work takes place: ‘as black female leaders of an art therapy group, therefore, the fact of our blackness will colour how we understand or speak about what happens in the group’ (Barber and Campbell, 1999: 34). Clarkson has pointed out that ideas and experiences of identity and relationship differ between cultures: some cultures don’t have the notion of an individualised separate ‘self’ at all. they think that ‘self’ is an absurdity – as if it makes any sense to say that a person can be separate from others – or from the rest of the universe . . . the importance of the group or family system in many cultures as the matrix for learning, resolving conflicts and facilitating healing is sadly contrasted with the individualistic (if exclusive) Western conception of the individual as separate from their culture, their family, their ancestral roots, their ongoing living communities, their one-ness with the fabric of their living spaces and with all of nature. (Clarkson, 2002a: 218) she notes the importance of being open to other paradigms of ‘humanbeingness’ (Clarkson, 2002a: 218). here the dialogues and mutuality discussed in this chapter – concerning the culture, beliefs, expressions, artistic traditions and views of the world – are relevant to the ideas of ‘development’ and ‘self’ brought into the arts therapy space. such views emphasise the necessary attention needed to foreground the individual client’s experience in relation to approaching therapy from a developmental perspective. they highlight the need to constantly acknowledge the complexities of areas such as power and difference. they bear testimony to the importance of dialogue rather than prescription within the arts therapy space, and in the relationship between arts therapist and client.

Dialogue with a mindfulness approach to therapy the following research example illuminates a dialogue between art therapy and mindfulness. the work creates an innovative combination of



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mindfulness, the concept of the art therapy studio and the experiences brought by clients who are refugees.

Focus on Research: the Inhabited Studio Interview with Debra Kalmanowitz and Rainbow Ho This interview is based on the research ‘Out of Our Mind. Art Therapy and Mindfulness with Refugees, Political Violence and Trauma’ (Kalmanowitz and Ho, 2016).

The Inhabited Studio: method and the client–therapist relationship participants attending the ‘inhabited studio’ were refugees and asylum seekers from different countries, including somalia, iran and liberia (Kalmanowitz and ho, 2016). they were all clients of a non-governmental organisation (ngo) in hong Kong, which worked with the practical and psychosocial needs of refugees, who were referred to the studio as they had sought emotional or psychosocial support. the context is described as being complex for refugees: ‘hong Kong is a signatory to the un Convention against torture, but not the un refugee Convention. as of april 2014, hong Kong had 47,000 asylum seekers registered in the city’ (Kao, 2014). asylum seekers are not allowed to work or study and can wait for many years for their claims to be heard’ (Kalmanowitz and ho, 2016: 58). the inhabited studio was named after ‘a fundamental principle in common between the art therapy and mindfulness – the practice of being in the present moment in an accepting and non-judgemental manner’ (2016: 59). in the studio art materials were made available and introduced to the participants but no theme was given. at the same time, mindfulness was introduced ‘through teaching of a variety of formal and informal mindfulness exercises’ (2016: 59). the approach of the ngo and the studio included ‘work with the external world (eg. social systems, communities, schools, families and cultural and religious institutions) as well as the internal world (eg. psychological support, prayer)’ (2016: 57). Whilst being aware of not solely ‘medicalising’ the participants by being aware of the political and social aspects of their experiences, the researchers note the situation many of the participants found themselves in: in addition to the social dislocation, the participants suffered from physiological symptoms such as hyper arousal, anxiety, aches and pains, difficulty in concentrating. many felt displaced and disconnected, some felt isolated and alone and all described structuring their days around activities that would keep their thoughts at bay. (Kalmanowitz and Ho, 2016: 57)

262 Client–therapist relationship  they use the concept of ‘trauma’ as being relevant to the participants’ experiences and related it to the studio’s approach in exploring the potential of mindfulness and art therapy: trauma is responsive to mindfulness in that it works towards increased awareness and acceptance rather than to the decreasing of awareness and of shutting down and can assist in both emotional processing as well as cognitive processing through this attitude of acceptance, non judgement and present focus. For these reasons mindfulness has become a core component of trauma therapy as part of the CBt [cognitive behavioural therapy] approach holistic approach to working with refugees. (Kalmanowitz and Ho, 2016: 58) one example of the approach involved participants being introduced to what the art therapists describe as ‘mindfulness breathing meditation’: titus, a young man from liberia described how quickly he lost this internal sense of safety: ‘Yea, sometimes, when i am breathing fast. i just go sit down in a chair. i don’t know if you had such an experience . . . sometimes . . . my heart start to beat fast . . . Yea, yea . . . as if you were caught or something like that . . . Yeh yeh, like someone is ill. as if someone scares you . . . and you feel that emotion. it sometimes happens to me’ . . . ayana from somalia described how the mindfulness breathing meditation allowed her to calm down from exactly this feeling described by titus. ‘i liked it it made me relax . . and it made me not think so much about my bad memories’. (Kalmanowitz and Ho, 2016: 59)

Amiin: aims of the therapy the researchers identify a series of ways in which mindfulness and art therapy connect. the following is an extract concerning amiin, a young man from somalia, who arrived at one of the sessions in the studio ‘fustered’: he sat down, but could not be still. he talked non-stop, but not in a coherent fashion and created an unsettled feeling in the studio which had already begun. he had just been to immigration for his regular sign in, but this time they had not followed the same routine and he was convinced that something was wrong and that he would be deported back to his country. the art therapist listened as amiin recounted his experience over and over again. amiin was talking, but this did not seem to be leading to a sense of



  Dialogues and diversity 263 relief, in fact it seemed to contribute to an escalation of his fears and anxiety. the therapist suggested that amiin try to take a piece of paper and some pencils and oil pastels and draw. at first this seemed a strange request, but very soon, amiin’s body began to calm and he became more present in the room. after a period of time he handed his drawing to the art therapist. amiin had drawn his concerns. his image shows how overwhelmed he felt. he had placed himself and his problems in a box and written clearly how they made him feel. the metaphor of the box emerged out of engaging in process and not out of thinking. this seemed to contain him, hold the problems and move him from the confused state in which he arrived to a sense of equilibrium where he could think again. (Kalmanowitz and Ho, 2016: 60)

here the client arrives, bringing his experiences and situation into the studio. the art therapist listens, suggests an activity and notes amiin’s responses. this arrival and connection is described in relation to the space and presence of others, both clients and therapists. Contrast is made between the client talking without relief and the therapist listening and then using her relationship with amiin to offer suggestions linked to arts processes and materials available in the studio. the act of making art in the context of the space and relationships is connected to calmness, in-the-moment presence, containment, holding and the restitution of thought. the researchers talk about the nature of the combination of art therapy and mindfulness in the following ways, which relate to the vignette involving amiin, the therapist, the other participants and the studio: •

•

• •

through the experiential nature of mindfulness meditation and art therapy, participants in the group were able to connect somatic experiences of trauma with visual or symbolic representation. acknowledgement of suffering is integral, but the focus is on wellbeing, rather than trauma or pathology. Amiin was ‘overwhelmed to the point where he could not think’. The group had expressed the desire to be able to regulate their physiological sensations and the combination of art therapy and mindfulness-related focusing helped to ‘regulate the physiological responses which governed their days so that they were more open to new information and experiences’. the presence of the group allowed for individuals such as Amiin to be seen, witnessed and heard (even without words) and in so doing served to share and normalize behaviour and expression. a sense of trust was formed in the studio, and ‘camaraderie’. (summarised from Kalmanowitz and ho, 2016: 58–64)

the therapists have used their knowledge of art and mindfulness to create relationships and a space that enables the clients to effect change. they

264 Client–therapist relationship  have innovated a studio where particular kinds of activity and relationships are available. the following interview explores how the therapists see art therapy and mindfulness, their support of the clients developing their own agency in relation to the materials and process, to themselves as therapists and to each other as group members.

Case example analysis i felt that you were articulating something that developed from the more usual ‘triangular relationship’ between art therapist, client and art form: the space itself seemed to be a key fourth element. By this i mean that you talk movingly of the ‘inhabited studio’ as a physical and metaphoric state. in retrospect, what do you think were the key ways in which this space related to the ‘triangular relationship’? KalmanoWitz and ho: the inhabited studio facilitates process-oriented work and draws on the principles of a traditional art therapy studio. the creation of a safe space and non-judgemental environment, with clear boundaries in which each individual can engage in their own process, in the presence of the group. the triangular relationship refers to the multidirectional triangle between the therapist, the client and the art work and emerges from a psychodynamic approach to art therapy. this places emphasis on the therapeutic relationship and thinks in terms of transference and counter-transference with a primary focus on the relationships and the internal world of the individual. although an invaluable way of understanding art therapy and the therapeutic relationship within the art therapy context, this is not the chosen language of this research. relationships in the inhabited studio necessarily include the broader context of the individual in addition to the conscious and unconscious. the inhabited studio looks at the individual in relationship to their world view, culture, community, society, social and political situation, as well as their art work, the group and themselves (their own thoughts and feelings). the therapist in the inhabited studio is concerned with the facilitation of the creative, artistic and personal process in the presence of the group with a focus on the experience. the inhabited studio aims towards self awareness as emerging out of engagement in the process in the present moment. Jones: You note many ways in which art therapy and mindfulness connect, summarised very effectively as the ‘eleven features’ (2016: 63). looking at the research, how do you see these elements connecting especially to the hong Kong context and the refugee status of the clients? KalmanoWitz and ho: the context of refugees and asylum seekers is similar all over the world. the issues they face; of living in limbo – in a state of not knowing, and waiting to hear their fate can lead some to feel disillusioned, lost, confused and disempowered. dislocated from their past and everything that once defned them, separated from family and Jones:

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friends and having to create a new identity and life, despite tremendous loss and traumatic experiences, represent a common refugee experience. in addition, many refugees do not come from Western countries so that the help they seek and their understanding of therapy itself is shaped by their world view and their cultural attitudes towards health, illness and healing. this affects their approach towards therapy, and impacts on what they consider important and helpful. specifc to the hong Kong context is that hong Kong has not signed up to the un Convention for refugees (article 51). this means that as a country hong Kong has no commitment to eventually accept the asylum seekers. asylum seekers in hong Kong cannot work or study legally, leaving them dependent on handouts and unable to move forward with their lives. despite the specifc hong Kong context and the fact that mindfulness meditation emerges from an eastern tradition, the inhabited studio is by nature fexible enough to accommodate a variety of cultures and this would be no different in contexts like the united states or the united Kingdom. it is adapted to the refugee experience and the culture of the participants and not to the specifcs of hong Kong. Jones: You mention the importance of ‘viewing of thoughts as thoughts rather than reality’ (2016: 60) within the work. how did you see your role as art therapist in relation to this? KalmanoWitz and ho: viewing of thoughts as thoughts rather than reality implies an ability to create a distance between oneself and the emotion, experience or thought. this is perhaps an untraditional response in therapy. a more traditional approach would be to facilitate the expression of the feeling or the thought/memory and move towards working this through. the practice of mindfulness meditation reminds us that just as important as expression is the ability to gain some distance. With distance the individual is less overwhelmed and more likely to be able to begin to assimilate that which is diffcult. the role of art therapist in the inhabited studio is to create a safe, non-judgemental and accepting environment for participants. an environment in which they can explore their own thoughts and feelings with authenticity and if possible with some distance. they can experience an environment which is trusted and learn to be present and compassionate with themselves. the role of the therapist is to take into account each individual’s needs as well as to hold the paradox between distance and closeness and to help the individual to move between these.

Mindfulness and the arts therapies: critiques and limitations in retrospect, what do you think are the strengths and limitations of practice connecting art therapy and mindfulness?

Jones:

266 Client–therapist relationship  incorporating art therapy and mindfulness in work with refugees allows for a focused and yet broad approach with people from different cultures and world views. the possibility of engaging individuals through different modalities; visual (symbolic) and through the body (kinaesthetic and the senses) allows the model to be adapted to different world views and cultures and mirrors different traditional healing practices. the strengths lie in the present focus and process-oriented approach which allows for depth and surprise in a very short space of time. Work in the inhabited studio does not actively seek to solve the multitude of problems or integrate the diffuse memories of trauma, but draws on individual and group strengths while staying present with the very painful memories and experiences. this research indicated that in doing so, participants found that they felt more in control of their own bodies and emotions and could use the tools explored in the studio to cope better in their day-to-day life. the non-linear nature of this work allowed individuals in the studio to remember themselves as a whole rather than made up only of their traumatic experiences and current struggles, and in this small way the studio contributed to the building of resilience. the limitations lie not in the combination of the two, but in the short-term approach explored in this research. inhabited studio in this research was conceptualised to support those that could not commit to a longer term structure. despite the need for a short-term approach and the brevity of the studio being deliberately created to accommodate this reality, the brief nature of the experience could be seen as a limitation. although participants reported using what they had experienced inside the inhabited studio, outside in their daily lives, the practice of art making and mindfulness as well as art therapy have broader applications which could not be benefted from and expanded upon in this short space of time.

KalmanoWitz and ho:

such ideas reveal the importance of the arts therapist being aware of the ways different aspects of identity and relationship form and develop between therapist and client. they use terms such as ‘teaching’ techniques, offering ‘homework’ as clients are given activities to transfer some of the positive experiences and ways of being and meaning making in the studio to their lives outside and to bring those back to the group. as in the vignette with amiin above, the therapists facilitate activities and suggest to clients what they might do. such ideas develop new interpretations of the identity and role of the arts therapist and the nature of the space they create

Dialogue with different therapeutic paradigms compared the case illustrations above demonstrate the nature of the true dialogue that can occur between the arts therapies and other therapeutic paradigms.



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in each we can see the way that, though the practice is informed by analytic, developmental or mindfulness frameworks for therapy, the relationships between client and therapist refect unique ways of working which brings together the arts therapy with another therapeutic paradigm. We can see that the art form and arts process affect the nature of the relationship. this is illustrated by the ways of engaging actively with the arts form, the benefts of arts as communication and expression, together with the ways creativity features in the exploration and resolution of the client’s issues. each of these case studies, though working in dialogue with different therapeutic paradigms, have much in common. the pieces of work emphasise a developing relationship between client, art form or process and therapist. the therapy involves participation in an art form for the client: they play instruments, improvise with movement or use image making. they position the arts as a communication of relationship, and as an indicator of change. all argue for the particular potency for the client of the non-verbal aspects of the therapy. none sets fixed targets for change, but attempt to follow the client’s potential and lead (aldridge, 1996: 268). the goals have differences, however, and the nature of the material encountered also has differences. For aldridge, the arts therapy space is an opportunity for the development of capacities that will be reflected in the client’s ability to communicate in relationships outside the session. Change in the client’s capacity to develop musical dialogue is seen to ‘bring about improvement in the ability to form and maintain personal, social relationships in other contexts’ (aldridge, 1996: 269). the therapist’s responsibility to the client is to assess the developmental issue, and then to frame the ways in which the music and the support of the therapist can most effectively follow the child’s developmental needs. the client experiences the therapist as a support and they play music together, improvising and creating a musical dialogue. For dosamantes-Beaudry the therapeutic space, relationship and movement interact and combine to reflect and impact on aspects of the client’s internal world and their relationships with others: all become symbolic of the world held within the client. the client–therapist relationship becomes an arena for expressing and renegotiating this internal world. Kalmanowitz and ho talk of the role of the therapist as including the creation a safe, non-judgemental and accepting environment for participants and this is connected to aims of exploration of thoughts and feelings with authenticity and with some distance. the role of the therapist is to respond and facilitate involvement in ways that support each individual’s needs and to help the client to engage with distance and closeness and to see themselves in a more integrated manner.

Why the diversity? Clarkson, in reviewing research on the therapeutic relationship in psychoanalysis, counselling psychology and psychoanalysis, asks a series of questions relevant to the array of approaches within the arts therapies. these

268 Client–therapist relationship  are: why are there so many different approaches? Why does the relationship between therapist and client appear to be more important in assessing the effectiveness of psychotherapy than any of these different approaches? are the approaches talking about the therapeutic relationship, but from ‘different universes of discourse or focusing on different aspects of it?’ (Clarkson, 1998: 75). her work involves identifying the variables, and then analysing them in terms of commonalities and contrasts. the five kinds of relationship she identifies within her research are: the working alliance; the transference– counter-transference relationship; the developmentally needed or reparative relationship; the person-to-person or real relationship; and the transpersonal relationship (Clarkson, 1998: 84). her hypothesis is that these kinds of relationship are present in most approaches to therapy. my analysis in this chapter has drawn on Clarkson’s approach by identifying commonalities and contrasts between the examples. a fair question to ask is whether the clients are best served by the ways of relating chosen by the therapist. Could elizabeth, for example, be better served by the way of relating chosen by aldridge than that chosen by dosamantes-Beaudry, or sophie by Kalmanowitz and ho’s approach? i think that in these cases the clients and the approach taken seem to reflect the client’s needs. the clients have been referred with different presenting issues – as described earlier, sophie’s concerning developmental issues which create problems in relating or elizabeth with relational and relationship issues. referral seems to reflect the areas of need and growth for the client. each therapist works within the paradigm used by the service the client is referred to. the client dosamantes-Beaudry sees is within a psychodynamically orientated service; aldridge’s work takes place in a setting that aims to work developmentally. elizabeth’s work enables her to return to early experiences and work with relationship issues. For sophie the language and developmental possibilities made available within the music seem to fit her needs appropriately. here is an illustration of the kinds of commonalities and contrasts of which Clarkson speaks. We’ve seen in the examples that there are differences, but these seem to meet the needs of the clients. such variety and diversity are necessary to reflect the complexities of the situations clients bring to the potentials of the arts therapy space and relationship.

An arts therapies approach versus approaches related to other disciplines some arts therapists, such as milioni (2001), have been critical of arts therapists working within specifc paradigms. she echoes Clarkson, emphasising the importance of exploring ‘meaning for the client’ rather than what she calls, ‘theory-prescribed imposition of meaning by the dramatherapist’ (milioni, 2001: 15). though i would argue that none of the work described in this chapter falls into such a category, it is important to take note of such a criticism. the danger is that the paradigm can affect the capacity of the



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therapist and client to work mutually. it might stop the therapist seeing clearly so that they ft the client’s experience into their paradigm, rather than trying to see what is occurring as clearly as possible, and to recognise the individuality of the contact between therapist and client. others are critical of the stance we have looked at in this chapter: of arts therapists allying themselves with paradigms seen to be ‘outside’ the arts therapies. many arts therapists would argue that whilst their work has a dialogue with other disciplines their practice is rooted in the specific theory and methods of the arts therapies. though the history of the arts therapies gives an indication of their growing in dialogue, or in parallel, with other disciplines, they see their practice as having a distinct identity and way of working that is not based in the therapeutic framework of other approaches. often these approaches see themselves as strongly allied with the art form or arts processes within the arts therapies. Case material in the next chapter will explore the client–therapist relationship from such perspectives, to develop our understanding of the range of ideas and approaches within the arts therapies.

sixteen

Client and arts therapist: traditions and discoveries Introduction The last chapter looked at the relationship between the client and therapist in the arts therapies using the concept of ‘dialogue’, drawing on a variety of frameworks and traditions of therapy. This chapter looks at the role of the arts therapist in different ways, in order to try to develop further understanding of what an arts therapist is, and does. It will explore, for example, the ways that the arts therapist brings the function and role of the artist to the therapeutic encounter. It will also address new challenges such as that identifed by Talwar, to ‘push the boundaries of traditional knowledge cultures of art therapy’ in ways that are ‘committed to diversity and inclusion’ (2016: 118). It’s worth noting that many trainings throughout the world emphasise that, prior to entry, the arts therapist must have a qualifcation, or extensive experience, in an art form, and also that the trainings themselves include a substantial amount of experiential work in the art form. Once qualifed, professional organisations often require that the therapist continues to engage in their art form as an artist. Looked at in one way, this contrasts with the statement often made by arts therapists to clients, and often written about in arts therapies literature, that the client need not have prior experience in the art form to beneft from the arts therapy. It might be possible to say that this creates a divide between the trained, artistically literate arts therapist, and the client who may never have painted or danced before. This might be seen to create tensions or diffculties in the relationship, where the therapist becomes strongly identifed by the client with the expertise and mastery of the arts arena of the therapy. This dynamic varies, however. As we shall see, though these issues can be present, the reality is often more complex than this.

Role of the arts therapist: therapist and client, artist and artist together How is the ‘artist’ role of the arts therapist present in the therapy? A part of the answer to this might link the therapist to the arts through the therapy space and the materials in the session. For many clients the therapist becomes allied 270



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with the artistic space, the room or studio, or to the materials they bring such as musical instruments, clay, mask or prop. Here, the arts therapist becomes someone who offers or enables access to the arts. They are, whether they are participating actively in using the art form themselves in therapy sessions with a client or not, someone who becomes linked to creativity. The therapist, by offering materials such as paint, may be seen by the client as an artist. At its most basic, this will be because they offer the opportunity to use an art form, and there is the expectation that they will be present whilst the client is engaged with arts media and processes. In some circumstances they may sit in a room where artistic materials are available, though they themselves do not directly engage in active art making themselves – the materials and the space being latent to the potentials, desires, blocks or resistances of the client. In others, they might create activities to enable the client to enter into arts making, facilitating the client but not actively taking part in expression directly themselves. Other approaches may involve the therapist actively working with the client by creating art together – their dancing or improvising with each other being an integral element of the therapy. As we have seen, a music therapist may play the piano whilst the client listens, and an art therapist might engage in drawing on a sheet of paper at the same time as the client. As we examined at the start of the last chapter, a dramatherapist might take on an active role within a client’s enactment, or a dance movement therapist might engage in dance with a client. Here the therapist’s experience, skills and language as an artist are brought into their active use of the art form within the work. This is seen to function in a number of ways. Firstly the therapist, by using the art form, can enable the arts to become a part of the therapy: for example, the therapist playing an instrument. This might be seen to encourage the client to enter into, or experience, the art form. It might also be a way for the client to develop a route into expression: playing or dancing with the therapist. Here they can begin to accompany the therapist as a way of participating; this can then be developed to enable them to discover the expressive potentials of the art form, to communicate their own cultural arts forms or find their own ‘language’. As the chapters in Part V show, the relationships between the therapist’s and client’s cultures are an important dynamic within the arts therapy. The therapist might also choose to make an intervention, interpretation or response in movement, music, paint or in role. Here they use the language of the art form to connect with the client’s contribution. Skewes says that the music therapist is creative in ‘both their music making and in their therapy’: ‘Musically, it is essential for the therapist to be creatively present, responding in the moment to the musical material of participants, enhancing what is being heard or playing something that opens up the possibilities of the art form’ (Skewes, 2002: 51). She might play to assist the client, to help ‘knit together’ strands of music, or to use ‘their creative sense to determine where the music leads and what journey it may take’ (2002: 51), or in responding and using words in relation to the music. Skewes emphasises the role of intuition, the need for the music therapist to be ‘musically intuitive regarding the aesthetic sound of the group . . . playing when they think their

272 Client–therapist relationship  music will assist the group . . . and judging how subtle or direct the form should be’ (2002: 51). Here the therapist is using their art form in communication with clients. In addition, they are attempting to connect with the client’s world through the art form, using the music language or expression of the client. The manifest content – the therapist’s gesture, sound or words spoken in role – might be an important part of their response. However, the fact that the therapist is participating at all might have an equally important role to play. As we have seen in the last chapter, the therapist’s engaging in the art form might be experienced by the client as a recognition of their inner world, or of their experiences expressed through the art form: they might feel seen, heard or responded to. The therapist’s participation might evoke role connections for the client – of parent, playmate, rival: these may be positive or negative – but all are a point of contact. This evocation can bring the client’s culture and associations, for example of past problematic relationships, into the therapy room, and can enable them to be worked with through the mutual participation in the art form, as client and therapist dance, paint or make music. Some have spoken against the therapist’s active involvement as participating artist in the art form within the therapy. They argue that the experience might be overwhelming for the client, that the therapist may be unconsciously displaying their own needs or agendas in an unhelpful way by taking part. Skaife (1995) has pointed out some of the complexities in these areas: If the art therapist encourages verbalisation is she directing the client away from expression through the artwork? If the art therapist only talks and does not paint what sort of unconscious message is she giving? If she paints, how does she model authentic expression of deep feeling without shifting the attention in the therapy onto herself? How does the art therapist balance the need for a reality-based attitude towards the practical aspects of art-making, with the more reflective attitude required in response to verbal communication? (Skaife, 1995: 7) She rightly does not point to a simplistic answer, but indicates the need to engage with these issues and the tensions of the therapist’s involvement and role within the arts therapy. Whatever ways the therapist participates in the therapy, she or he is using the part of their identity that is an ‘artist’ within the session. Their knowledge of the art form will have an effect upon their experience of the client. For example, their knowledge of clay may be used in seeing how the client responds to their work. The way the client manipulates the clay could be a source of the development of relationship. Similarly, how a client uses their body in dance will be a part of the way a dance movement therapist



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relates to the client. In this the therapist is using their knowledge of, and familiarity with, the arts form and its possibilities. They will not only draw upon their own creative experience, but also their knowledge of cultural traditions and the accounts of artistic practices which others have made. So, for example, the way the client takes up role, uses their voice and body will be responded to by the therapist as an artist with knowledge of the way character portrayals can develop, or with traditions of movement to draw upon. This knowledge of the art form feeds their interactions and responses to the client. Similarly, an element of the therapist’s function is to enable the ‘artist’ within the client to come to the fore. This, in part, concerns the therapist’s enabling the client to engage with arts media and processes, but the matter is more complex. As the client brings their life into relation with the therapeutic space, and as their creativity is expressed and developed within the sessions, so their capacity to relate creatively to the life problems or issues they are encountering within the sessions is seen to be enhanced. This does not mean that it is always necessary for the client to be creative within the session, only that the potential is there. Nor is it the case that the client is on an evolving path of increasing creativity or artistic competence. This is not usually a goal of the arts therapist. Rather, it is that the space can be an opportunity for this element of the client, the artist, to come to the fore. The client may, at various times, feel unable to use the space, feel uncreative, antagonistic toward the art form or therapist – but the potential is there. Clients often express feelings of being blocked or uncreative in their lives, and the expressions and feelings of being able to be creative or expressive may enable the client to feel empowered. A client may have issues relating to feeling incapable, unacknowledged or unseen, for example. The fact of making may enable the client to experience themselves differently, as someone capable of having effect, or of being recognised or witnessed. The creative process may also allow the client to permit feelings and memories concerning these aspects of themselves, and their lives, to be reflected in their experience of themselves as artists within the sessions. It is important that the arts therapist continue to function as an artist. Otherwise they might try to realise their own needs or issues about creative expression through the client – to live vicariously through the client’s artistic process. Gilroy (1996), in her research with art therapy practitioners, reports that therapists who were still actively engaged in their own art making found in it refreshment, self-affirmation, self-discovery and insight. The concept of the ‘artist’ being present alongside that of the ‘therapist’ can help illuminate aspects of the arts therapist’s process. They also may experience blocks, periods of turmoil: lacking inspiration within their work. This is important to look at in terms of the ‘artist’ part of their role in relation to their own creativity. It may also be seen, within some approaches, to be a part of the transferential and counter-transferential process. The therapist’s experiences of their own creativity and identity may be linked to the client’s work within the therapy space. Hence the

274 Client–therapist relationship  ‘artist’ and ‘therapist’ elements of the arts therapist work together to create meaning out of such experiences.

Traditions, assumptions, discoveries It’s important to acknowledge the different traditions and assumptions which the arts therapist and client bring to the therapeutic relationship in the light of these ideas. Skaife (2000) usefully considers issues of acculturation, and the potential power of the arts therapist in relation to the client’s work. She points out how important it is for the arts therapist to keep in touch with the creative, artist aspect of their identity in relating to clients within their therapy practice. If the therapist only comments on the content of the work, for example, this may encourage the client or the ‘artist/ patient’ as Skaife says, to focus too much on the ‘message’. If the therapist only comments on the process which the client is engaged in when making, this may ignore aspects of the content which the client might wish the therapist to be aware of. Similarly, if, in a group, the therapist confnes comment to the group process, the clients are likely to involve themselves less and less in the art. It’s as if the client refects the aspect of the role identity and framework brought by the therapist. Another aspect of the way in which the arts therapist and client encounter each other relates to the ways they discover or learn about the art form within the therapy space and the therapeutic relationship. In a sense, this is a mutual process: both therapist and client are in a process of creative discovery about the experiences, languages, processes and potentials of the arts form. This involves, for example, the ways in which the therapist enables the client’s use of the art form in the therapeutic space. Some would, rightly, argue that most therapists do not directly ‘educate’ clients on how to use an arts therapy session. Many approaches work to engage with the client’s own languages and forms of creative expression. This varies according to the model of therapy, however. The client’s experience of the therapist within a developmental framework will be different from that of one within a mindfulness orientation, as we have seen. The extent of the ways the arts therapist role relates to that of a ‘teacher’ or ‘mentor’ present within the therapy may vary according to the model within which the work takes place. Some clients may arrive at the sessions with either the skills or capacity to use the art form. However, as mentioned earlier, it is understood in all the arts therapies that a client need not be conversant with an art form in order to use the arts therapies. For clients who feel they have little experience of the art form, an aspect of the work might involve the therapist’s helping the client to discover the arts therapies’ expressive forms and the therapeutic possibilities within this. A psychotherapist working with verbal language alone does not normally create introductory exercises in which the client might use words, making suggestions about exploring different ways of using their voice or talking, for example. However, in many societies the



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relationship that clients have with art forms is different from their relationship with the spoken word. There are differences between, and within, different cultures. So, for example, in some societies song and movement is more generally prevalent as a participatory activity than in others. Some have argued, for example, that in many Western cultures participating in art making is more a part of children’s lives than of adults’ (Slade, 1995). As we considered earlier, many adults and children may be consumers of the arts, but not active participants as ‘makers’. The engagement between client, therapist and art form connects to the social and political dimensions of the client’s experiences and life. Some have brought attention to particular aspects of this: for example, the ways in which access or participation in the arts is a power issue. Some sectors of society are seen to have been provided with more access as consumers or participants to the arts, others have not, and this is seen as a part of a wider issue of disenfranchisement or disempowerment. People with disabilities, or groups and individuals from groups not of a majority culture, are seen as being cut off from consuming and expressing their identity through the arts (Pickard, 1989). Some would see such offering of opportunities for expression and for creativity as a crucial part of the arts therapies. As discussed in Chapter 7, this is different from the arts activities that are deliberately giving opportunities to redress political imbalance to access in the arts. However, this may be an important element within arts therapists’ practice. The need is to recognise that some individuals and groups will be alienated from artistic expression. This is a part of the dynamics between therapist and client that may be at work within their sessions. This dynamic might manifest itself in the ways in which a client feels unfamiliar with the art form. It might manifest itself in the way a client associates the arts experience in the arts therapy with the last time such activities were engaged with by them. This might, for example, have been as a child – so the art experience may be seen variously as an opportunity to be free as a child, or be dismissed as ‘childish’. Memories and associations from that time might also accompany this. The artistic space can be accompanied by memories and feelings from this time: this might be conscious or unconscious. Similarly, feelings and responses accompanying issues such as disenfranchisement may also come into the session. If, for example, the client experiences being silenced or sidelined by a mainstream culture, this may enter into the process of the therapy. If the therapist is not familiar with the cultural forms or background of the client, this might repeat the process of disenfranchisement and disempowerment. As touched on earlier, there are a number of power-related issues potentially present in the ‘teacher–pupil’ element of the therapeutic relationship. Many therapists see it as crucial that they are aware of the potential power structure: the therapist is the one who may ‘own’ the rules and means of the art form. They become the experts, the client the novice. For some forms of therapy, for example in arts therapies work influenced by cognitive behavioural therapy, the potential exploration of this aspect of the relationship would be minimised; the focus is on the creation of an alliance, and for the

276 Client–therapist relationship  client to develop their own relationship with expression. In other ways of working, such as those influenced by an analytic approach, this aspect of the relationship would be made visible, interpreted and explored. In her review of music therapist practitioners in the USA, Skewes found a diversity of practice reflecting these issues. She concludes that the level of structure and direction used by therapists varied in accordance with the philosophical stance and the clientele they worked with. She says that: those clinicians who worked with verbal clients, or maintained a transpersonal philosophy, were more likely to assume a non-directive leadership role, allowing the group to find its own meaning and follow its own volition. Specialists with a focus on interpretation were more likely to desire a verbal consolidation of what had occurred musically, in order to facilitate cognitive insight and behavioural change. (Skewes, 2002: 54) Wood says that, upon first meeting, clients may understand that talking to someone might help, but often wonder, ‘why I might suggest them using art materials’. She goes on to acknowledge a teaching element to first encounters: I think it would be extremely difficult to be non-directive about the art materials, at the very least I think I have to show my clients where the materials are and make it clear to them that they can use whatever they want. Also at some point early on I indicate that if the materials they feel inclined to use are not there in the room then between us we can do our best to improvise and bring additional materials from outside to future sessions. (Wood, 1990: 8) Most arts therapists do not see themselves as teachers in the sense of being directive and instructional – it is rather how, as Wood puts it, they ‘introduce the possibility of art work appropriately’ (Wood, 1990: 11). At the start of many arts therapies sessions issues such as confidence, familiarity and skill can be at the fore. Some have questioned the nature of statements, looked at earlier, saying that the client need not ‘be good at’ art: In a sense this admonition tells them that art making is not what is important, but ‘telling something’ through using art – in other words a conceptual idea – or finding something out that is hidden in the art work. We are certainly not inviting them to use a therapeutic tool in which it is possible to really engage with their feelings. (Skaife, 2000: 119)



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The main role of the therapist is not to teach, but to see how the client relates to the arts space and process, and to try to enable the maximum opportunities for arts therapy to occur. As we have seen, the specific way this can happen varies according to the approach of the therapy – but the primacy of this therapeutic function is a constant.

Focus on Research: dance/movement therapy, resilience and recovery Interview with David Alan Harris This interview is based on the research ‘Dance/Movement Therapy Approaches to Fostering Resilience and Recovery among African Adolescent Torture Survivors’ (Harris, 2007). The following research explores the dynamics between the roles of artist, therapist and client: particularly concerning culture, knowledge, power and relationship. Harris’s research addresses the nature and impact of dance/ movement therapy interventions, whether and how they can ‘enhance healing’ among African adolescent survivors of war and organised violence in work designed to ‘promote cultural relevance and community ownership’ (2007: 135). The research focuses upon two initiatives, one programme involving South Sudanese refugee youths resettled to the USA, the other with youths in Sierra Leone. Harris’s work situates the role of dance in the context of therapy with these young people in the following way: Engaging cultural resources, including those associated with creative artistic expression, has been shown to enhance communities’ resilience in the face of terror and deprivation, and to cultivate children’s capacities in particular. Dancing is one such expressive activity, the collective performance of which delivers strong potential for sublimating inter-group tensions, while increasing interpersonal connection and strengthening solidarity. Although rarely utilized as modes of psychosocial intervention, dance/ movement programmes, if appropriately designed to maximize cultural relevance, may prove an effective means of fostering resilience after massive violence. (Harris, 2007: 135) Harris notes that the two initiatives articulated differing methods for achieving similar goals ‘in the promotion of resilience and recovery after exposure to extreme traumatic incidents’: (1) desomatizing memory, (2) nurturing experiences of mindfulness,

278 Client–therapist relationship  (3) enabling meaningful experiences for the contained discharge of anxiety and aggression, and (4) unleashing the pleasure of creativity, and thereby freeing participants to symbolize their traumatic losses and future hopes. (Harris, 2007: 141) The practice included improvisatory dancing and other structured creative exercises, often performed to recordings of the latest Sierra Leonean popular music (2007: 150). Some activities were structured, others improvisatory dance movement: Some activities provided a container for the physical discharge of aggression as a way of reducing anxiety, while others promoted relaxation or offered skills for overcoming sleep disturbances or minimizing the impact of flashbacks. Participants devoted many hours over the course of several sessions to a number of creative exercises, some involving verbalization as well as physical expression through gesture and action and all designed to elicit symbolization as a vehicle for the clients to integrate their trauma. (Harris, 2007: 150) JONES:

When you were frst considering how to develop a response to the lives and situations of the potential clients, how did you draw on existing knowledge in the feld of the arts therapies – how did you work creatively/innovatively with fresh ideas? HARRIS: Dance follows an oral tradition in many cultural contexts, including even those with the most individualistic and least collectivist tendencies as that of the mainstream United States culture in which I grew up. Dancers, rather than learning their art form through memorisation of academic texts, tend to learn through training and apprenticeship with the generation of dancers before them. Dance is handed down bodyto-body, no less in the prestigious ballet studios of the Global North than in the dirt-foored classrooms of the Kerala Kalamandalam, where I once had occasion to watch young boys learning from masters the timeless rhythms of Kathak. Dance/movement therapy (DMT) training follows a similar trajectory. Replicating both such dance traditions and the structure of attachment in inculcating emotional intelligence, DMT trainers likewise typically hand down skills and techniques bodyto-body, from one generation to the next, often in small group formats. Often, while still in training, dance/movement therapists begin to develop a personal style derived from what they have learned in this way, and infected with signature distinctions. Accordingly, when adapting what we now call the Chacean Circle to serve as a therapeutic container for a group of teenage males in rural Sierra Leone who, a few years prior, as boy soldiers had all been involved in perpetrating atrocities, I was in fact largely guided by the attuned responses of my own



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body. I had been fortunate enough to incorporate the Marian Chace ethos into mindful muscle memory through rigorous practice with Sherry Goodill and Gayle Gates at the (now) Drexel University DMT training programme where I studied. Under their tutelage, I’d developed something of a refexive capacity to mirror others’ movement, and play with its dynamics in ways that might challenge old patterns and awaken growth. Just before launching the former combatants group, moreover, I had elicited feedback from another of my mentors, who had studied directly with Chace: Arlynne Stark met with me in person to provide detailed commentary on a videotaped session of my frst DMT group in West Africa – for a dozen deeply war-affected youths who had not been involved in perpetrating violence. Historically, innovation in DMT emerges from just such embodied teaching. In my case, the decision to study DMT in the first place was made in the awareness that I wanted a clinical career with refugees and other survivors of human rights abuse. Having already worked for several years, primarily as a writer, for human rights and refugee advocacy organisations, I was inspired to help expand DMT’s role in empowering survivors of torture and war. Learning while a student that Chace herself had worked directly with soldiers traumatised by World War II inspired me to examine the potential for adapting her model for use in a world in which hundreds of thousands of children were affiliated with fighting forces. Indeed, that same aspiration led me to focus in the article in question on disseminating findings of DMT’s flexibility of application, as well as its effectiveness, in fostering recovery from wartime traumas. Beyond drawing on the lineage of DMT, particularly as handed down from Chace, I conducted basic academic research when developing the two DMT groups (Poimboi Veeyah Koindu, and the Dinka Initiative to Empower and Restore). My survey of the literature over the final twentyfive years of the last century on therapeutic interventions with children affected by war informed my work in Sierra Leone with former boy combatants, as it did that in Pennsylvania with unaccompanied refugee minors from southern Sudan. These two very different programmatic efforts incorporated ideas from outside DMT, as well, which I encountered by reading about them rather than through unmediated, body-to-body training. My knowledge of the sociodrama form, for example, which proved so vital a part of the former boy soldiers’ revelatory role-plays about their wartime experiences, originated in a book chapter’s discussion of its use by a community healing project for children in post-conflict Mozambique. Similarly, my analysis of the social and healing functions inherent in Sudanese dancing and drumming depended in large part on my research into the therapeutic application of traditional dance in postwar contexts, and on theories of ritual function more broadly, particularly the seminal work of cultural anthropologist Victor Turner there. JONES: You talk about ‘considerable adaptation to social, cultural, and political realities’ – and of the parallels and differences between the

280 Client–therapist relationship  Dinka Initiative to Empower and Restore and the work in the Kailahun District of Sierra Leone. Can you say something about how these different contexts related to the way you and your clients considered a ‘successful outcome’ for the work? HARRIS: While the young people in Kailahun and those in Pennsylvania had numerous commonalities, particularly in terms of wartime horrors witnessed and losses absorbed, there were defning differences between them as well. In addition, the two environments presented quite distinct challenges and opportunities, which informed decision-making regarding intervention objectives, as well as our sense of what would amount to success in our work together. In Sierra Leone, arguably the world’s least developed country at the time, I served as Clinician/Trainer for a community healing and torture rehabilitation programme with a US nongovernmental organisation, supervising a staff of two dozen paraprofessional trauma counsellors for the Center for Victims of Torture (CVT). In that role, I co-facilitated the group that came to call itself Poimboi Veeyah Koindu (PVK, or Orphan Boys of Koindu in their native Kissi language) with three local staff, who participated as part of their on-the-job training. In advance of launching PVK’s first session, the four of us group leaders together established a list of seventeen specific treatment objectives, along with a session-by-session plan of activities. I had put considerable effort beforehand into thinking through the likely needs of these ex-combatant teenagers. This was, to my knowledge, the world’s first DMT group for former child soldiers; yet, when in graduate school in Philadelphia, I had written a detailed theoretical paper that proposed ways of implementing DMT interventions with children affiliated with fighting forces, and I adapted these findings for use in Koindu. Only after a couple of group meetings, however, were we facilitators to discover how very desensitised to others’ suffering that these PVK youths showed themselves to be. In response, my co-facilitators and I determined that the foremost objective for the youths in this group would amount to enabling restoration of their capacity for empathy. This was an outcome that DMT, given foundations in attunement and mirroring, and especially the refined practice of kinaesthetic empathy at its core, was unusually well equipped to promote. Ultimately, PVK members’ extraordinary success in coming to understand themselves as both targets and perpetrators of violence, to meaningfully mourn their losses, and to use dance and movement to represent the suffering of those they had hurt, amounted to real transformation. In using dance and drama to reconcile with the community that had previously spurned them for their viciousness during the war, the PVK youths advanced a path for themselves toward productive, adult roles in community development. They achieved an outcome that was entirely in keeping with their own needs as well as those of the people around them. By contrast, participants in the Dinka Initiative to Empower and Restore (or DIER, which is the Dinka word for dance), in Pennsylvania,



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found a way to use traditional dancing and drumming as a way of sustaining a viable connection to their culture’s defining strengths while undergoing the necessary adaptations to living as refugees in a new and very unfamiliar environment. The only message that I chose to verbalise with the Dinka youth involved regarding my rationale for their participation in DIER was that I had known many refugees in the USA, and that those who had thrived had been the ones who had held onto the strengths of their culture of origin. These young people found in their traditional dances, which they taught me at my request, a source of great pride and power. At the same time, many of them were drawn to new cultural practices and values, as represented by classmates they were coming to know in school or meeting socially elsewhere. Coming together to dance, to reconstitute the typical dancing circle, almost to transport themselves back to the heart of their culture of origin, afforded these young Dinka an unusual degree of support – something relatively few African refugees in this new host country are fortunate enough to experience. JONES: In retrospect, how much did the experience of work/research change you as a dance movement therapist? What did you and the clients learn together that was new, taking the edge of the feld forward? HARRIS: In both of these programmes, I worked with African adolescents who had lost nearly everything themselves, most especially the love and nurturance of family support that are so critical to shaping identity in collectivist cultures. Dancing together proved to be an exceptionally powerful engine for encouraging attachment and healing in the aftermath of such loss and violation, as has been shown in DMT for decades from Chace onwards. This work demonstrates, perhaps, that DMT may be usefully adapted for application in diverse cultural contexts, at least among youths from Sub-Saharan Africa. The PVK group, moreover, may serve as an illustration of how a time-limited DMT group may allow for successful passage through the three phases of recovery from traumatic distress, as perhaps best articulated by Judith Lewis Herman, MD: Safety, Remembrance and Mourning, and Reconnection. Indeed, PVK members’ triumph in reconciling with their community after the war – for which PVK won the international human rights award, the Freedom To Create (Youth) Prize for 2009 – stands as a new model for the application of DMT in fostering the restoration of empathy in postconfict communities. Similarly, DIER offers a DMT model worthy of replication in other refugee contexts. As coordinator, I asked the young people participating to teach me their dances. This simple structure immediately overturned the expected power differential by making the refugee youths the experts in DIER, and me the recipient of their collective and timeless traditional wisdom. This is an easily replicable process for use by dance therapists working with refugee groups everywhere, and I myself have adapted the idea in my work in individual therapy with torture, trafficking, and war trauma survivors from various continents: I find a way to focus on client

282 Client–therapist relationship  empowerment by asking clients to teach me something specific from their culture of origin. In this way, I am often able to subvert my own identity as a big, white, professional male from the country with the world’s mightiest military, and to build a sense of safety in the therapy room with a refugee survivor who may not otherwise acknowledge her own power. The DIER programme offers another potentially replicable model. The young Dinka in this programme had undergone one devastating loss after another, as do refugees everywhere. My motives in creating DIER were several, of course, and certainly involved a desire to provide these young unaccompanied refugees opportunities to experience pleasure and the vitality that may come from dancing fully. The ‘corrective emotional experience’ that I aimed for, and that I believe was achieved, however, was designed to foster more than this: resilience after loss. Accordingly, my overarching purpose for DIER from the outset was linked to the programme’s very termination. I had but one year to offer the programme, and in considering this time limitation, I realised that it offered an opportunity not to be ignored: to provide an experience for refugee youths who had undergone repeated traumatic losses to form a relationship through dance with a caring adult (myself), and to have a chance to prepare for that relationship to come to a predictable, and non-traumatic end. Unlike these youths’ experience with all the other adults in their lives whom they had come to rely on – all of whom had been taken from them violently – the DIER coordinator would leave on a schedule that they would know fully (and be reminded of repeatedly) from the programme’s outset. Ideally, this transition itself might facilitate growth and the building of capacity to cope effectively with all the other many transitions required of the new refugee in a new host country. Endings may promote growth and resilience, countering rather than reinforcing traumatic loss. In refecting on this innovative practice, Dieterich-Hartwell and Koch (2017) cite Subramanyam (1998) in their commentary on Harris’s work: The therapist needs to play the role of a witness and ‘provide a mirror for the individuals to look into themselves, to facilitate the process of change and create the necessary environment for the individuals to explore themselves’ (Subramanyam, 1998: 188). Clients are encouraged to find their own dance and slowly integrate all the different aspects of their world – the old, the new, the inside, and the outside. Harris (2007) in his work with South Sudanese refugees took on a role as facilitator, offering communal traditional Dinka dancing and drumming that was based on their cultural rituals. He noticed that over time, their collective resilience was increased as well as their capacity to acculturate and integrate into the host country. (Dieterich-Hartwell and Koch, 2017: 3)



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Dieterich-Hartwell and Koch go on to cite Dokter (1998), arguing that the arts therapies can be utilised to ‘support the maintaining of a cultural identity, especially in situations where some of that identity is lost or is in conflict with the dominant culture’ (1998: 16). They develop her concept that: Refugees may also be able to externalize their symbolized trauma through visual art, music, dance, or drama before they can access these verbally and, upon integrating, experience strength and positivity (Koch and Weidinger-von der Recke, 2009). The arts function as a shelter, the active involvement with them functions as taking ownership of constructing that temporary shelter. Aesthetic pleasure can be experienced like a protective cloak, shielding oneself from the aversive environmental conditions, bringing back a feeling of wholeness. Active creation of such aesthetic pleasure can be the means of experiencing resources, selfefficacy and resilience. (Dieterich-Hartwell and Koch, 2017: 3) Authors such as Talwar (2016) call for a wider frame of reference and understanding being brought to the arts therapist role in ways that create dialogue with Harris’s research. They argue that facilitators must learn as much as they can about the social and cultural contexts of clients and for a competency that recreates the identity of the arts therapist and the theory space: ‘the educational, social, and political mandates of the mental health landscape demand cross-cultural competence and social action, calling for a shifting definition of art therapy’ (Talwar, 2016: 117). Nadirshaw indicates the importance of factors such as being able to read the expression of emotions in different cultures, the necessity of the therapist aiming to work through their own attitudes, beliefs and prejudices, along with the different influences of culture on goals and tasks (Nadirshaw, 1992: 260). Case and Dalley speak of art therapy in a way that acknowledges this importance: It is . . . the process of image-making and how the final product is received within the bounds of a therapeutic situation that forms the basis of the art therapeutic process. It is here that the orientation of the therapist is of most importance in terms of how she receives and works with images produced. (Case and Dalley, 1992: 53) Callaghan (1996) places this issue right at the heart of the client– therapist relationship in her account of dance movement therapy with individuals and groups who are refugees from Africa, Europe, the Middle East, South America and South West Asia. She puts movement psychotherapy, and her own role and practice as a dance movement therapist,

284 Client–therapist relationship  within a framework defined by European and North American ideas and her own, ‘multi-cultural, predominantly western experience’ (1996: 250). She identifies the complex connection of issues regarding status, cultural practices, language and notions of relationship in such work. Callaghan stresses the need for these areas to be very much a part of the therapeutic relationship in a way which encourages ‘mutual dialogue’ (1996: 250). She uses the concept of culture in an interesting way. Callaghan places not only the identity and role of the client in relation to general issues concerning acculturation, for example to social structures or religious beliefs – but also sees the traumatic experience of the client in terms of culture. She says she works within an acknowledgement of both ethnicity and also the ‘cultures inherent in torture, such as the cultures of politics, trauma and refugeedom’ (1996: 250). She argues that the same elements of movement are used by all human beings: space, touch, rhythm, weight, eye-contact and gesture. However, it is the way these are used, and their meanings, that varies between individuals and cultures. The therapist–client encounter becomes a site where ethnic background and differences concerning areas such as touch, space and feelings can be acknowledged. The therapist, for example, if she or he is a member of the ‘host’ society, ‘partakes in a dialogue of mutual adaptation, and helps survivors explore how they can maintain their culture while adapting to the new one’ (1996: 260). Within differences of culture a therapeutic relationship based on the body can be developed. If this can acknowledge aspects of each individual’s ‘body culture’, then ‘the meaning of the body and movement in the person’s individual and cultural experience’ can be explored (1996: 260). The movement element of therapy, she argues, is an activity associated in many cultures with celebration, art and sport and is ‘acceptable’, whereas therapy and sharing feelings with strangers, sitting and talking might be uncomfortable, unfamiliar and alien. By focusing on movement that is culturally relevant, this can help build trust and the ‘unfolding’ of the client’s experiences. She points out an illustration of this in her work with clients who have been tortured. An Iranian client ‘stretched his thigh backwards, drawing an analogy to the ways camels were tied up in Iran to prevent them from running away – this enables him to develop into his own movements about being restricted and moving to avoid mines’ (1996: 258). The argument here is that, through the language and process of the artistic expression within the therapy, the client and therapist can find a way to develop dialogue concerning difference. The client’s experience of an art form within their own culture can begin to be worked with by the therapist as a way of validating the client, of engaging with their language and culture, and to try to begin to create a mutuality of expression. Implicit in what she is saying is that this can begin to assist the client to make use of the space to find a way to address their needs. This doesn’t fully acknowledge some of the issues regarding status or power and issues regarding cultures within which the notion of therapy is alien. However, it acknowledges the importance and the potentials of the artist within both



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client and therapist to attempt to create mutuality or dialogue through the art form and process. The following research explores a particular dimension of these issues concerning traditions and attitudes towards the therapeutic relationship and change. The researchers frame their enquiry as being connected to ‘the complexities of linking music-based experiences with the powerful notions of value, development and effcacy, legitimated by health, educational and social care frameworks’ (Pavlicevic et al., 2014: 6). It developed from music therapists asking, ‘What change means, for whom, and when . . . more particularly, where development and “progress” are not the dominant characteristics of music therapy work with young adults with severe learning disabilities’ (Pavlicevic et al., 2014: 8).

Focus on Research: long-term music therapy with young adults with severe learning difficulties Interview with Mercedes Pavlicevic This interview is based on the research ‘Making Music, Making Friends: Long-term Music Therapy with Young Adults with Severe Learning Disabilities’ (Pavlicevic, O’Neill, Powell, Jones and Sampathianaki, 2014). The context of the research is described as involving focus groups with professionals and with family members of clients with severe learning disabilities who had attended a Nordoff Robbins Music Therapy Centre’s ‘Saturday Club’ in the UK ‘for some years’. The research involved discussions based on participant opinions and in response to a presentation, including video material, about music therapy. The enquiry aimed to explore perceptions of how music therapy responds to the needs of clients with severe learning disabilities. The researchers relate their work to recent challenges involving ‘a critique of music therapy’s traditional emphasis on “the therapeutic relationship”, with its substantial psychological overtones’ (2014: 7) and a movement called Community Music Therapy (Pavlicevic and Ansdell, 2004; Stige and Aarø, 2012). This involves a theoretical shift: ‘through re-contextualising the musical–therapeutic relationships as part of, and within, people’s everyday social–cultural musical engagements and resources, Community Music Therapy has offered a broader socio-cultural reframing of music therapy praxis’ (Pavlicevic et al., 2014: 7). This frames the work the therapists and clients create together as responding to a ‘lack of support during life transitions’ and to the ‘lack of opportunities for peer friendships and socialising’ (2014: 16). The researchers situate this understanding of their role within a social model of disability – ‘developed in response to dissatisfaction with the limitation of a medical model’ – that understands ‘disability as generated through situations and environments that are themselves disabling, unable to

286 Client–therapist relationship  accommodate the person (however able)’ (2014: 16). Their findings are interpreted as seeing the therapeutic relationship and space being less about ‘directly addressing young adults’ individual/personal disabilities’ and more concerned with how the arts therapists and clients create ‘spontaneous and flexible therapeutic musical activities’ and ‘communicative and social environments’ through ‘making music together at times over years’ (Pavlicevic et al., 2014: 16) in order to facilitate: • • • •

experiences of fun, enjoyment, equality group belonging and intimacy confidence, self-worth and dignity opportunities to form friendships with peers. (Pavlicevic et al., 2014: 15–16)

The critique of the more traditional positioning of ‘the therapeutic relationship’ within such an approach is that it moves ‘beyond discourses of “therapeutic goals” and “disability” and beyond linear understandings of change’ (2014: 17). It naturally follows to ask how this affects the ways therapist and client see themselves and how they see change. The following interview explores how this shift in perspective broadens our understanding of the arts therapists’ and clients’ roles and their relationship to therapy. I was very interested in the notion of challenge in terms of the ‘traditional emphasis’ on the therapeutic relationship in music therapy which your research raises. What would you say are the main advantages to both client and therapist of offering a ‘re-contextualising’ of musical therapeutic relationships within ‘a broader socio-cultural reframing of music therapy praxis’ (Pavlicevic et al., 2014: 7)? PAVLICEVIC: The reframing was partly led by the long-term nature of the practice. Over the years, music therapy with their children/young adults was seen by parents as being about more than ‘music’ and more than ‘therapeutic’ (in the accepted therapeutic sense). Parents and carers increasingly engaged with the work from their own broader sociocultural landscapes – resonating with the therapists’ own expanding frames. This is emblematised by the title of the paper: ‘Making Music, Making Friends’, where friendship and music are experienced as inextricable, and also linked to the small intimate space created in sessions; rather than something that happens ‘outside’ therapy time. However, the reframing was also enabled by the music therapists, and this became understood more explicitly as the research group met and discussed over the months. The therapists’ re-contextualising frames enabled a disruption of therapeutic ‘custom and practice’ by everyday life, resources and identities. These were invited in, and woven through the therapeutic endeavour. This stance included constantly reviewing what it means to be a client and therapist; with roles and identities inhabited as fluid and responsive, rather than fixed by JONES:



  Traditions and discoveries 287 socially sanctioned expectations. For example, friendships between clients in a music therapy group become part of, and may extend beyond, therapy time. Practically, this meant celebrating friendships, recounting shared events outside sessions, and addressing difficulties and flashpoints as these arose both during and beyond therapy time.

The ambit of music therapy was increasingly understood as porous as well as protected – with music therapy understood as part of a social everyday ecology. For example, parents of clients attending music therapy groups formed social relationships with one another over the years– which led to attending one another’s birthday parties and meeting socially away from music therapy. How is privacy and confidentiality considered in such instances? And by whom? For what purpose? While hesitating to suggest that these are ‘advantages’, in our experience this broadening frame made both the study and the practice more ‘real’. Both were increasingly understood as entwined with everyday life, thanks to parents’ sense of commitment, social familiarity and trust. There was less pressure for the therapists to focus on ‘change’ in their work – and this emerging stance permitted the research-practitioners team to invite the practice to lead the research process. Crucially perhaps, the recontextualised framing – in the work and the study – helped the therapists to ‘keep the work alive’. You talk about the values and complexities of long-term work over ‘years’. Looking at the research, how do you refect on its fndings in relation to music, time, relationship and identity? PAVLICEVIC: The parents talking about their own sense of isolation and loneliness as a result of having a son or daughter with disability was one of the unexpected fndings. Linked to this was the value that both parents and professionals placed on intimacy – and that they saw music therapy as offering and enabling intimacy, which for them was a stark contrast to the constant hands-on care that the young adults received. Long-term music therapy relationships were reframed by the therapists as offering opportunities for a portfolio of needs-led, music-centred opportunities – without stagnating in dyadic or fixed group configurations, without worrying about ‘change’, waiting lists or ‘bed blocking’. The portfolio included music therapy provisions ranging from one-onone work; to small groups, larger groups, large ensembles, semi-public events and so on; with possibilities for drop-in sessions, sessions with parents, and possibilities for developing musical skills. JONES: How do you think the research affected the way the therapists saw their roles in relation to the clients and the people in the clients’ lives? PAVLICEVIC: The therapists became more alert to the needs of parents and families in particular as a result of the discussions in the focus groups, and explored possibilities for setting up parents’ groups. JONES:

288 Client–therapist relationship  The therapists also felt increasing responsibility towards seeking out musical pathways for clients, both within and beyond the Saturday clinic, informing themselves of local events and possibilities. Thus, experiences during session time could lead to therapists suggesting musical pathways beyond therapy time: performances to/with peers and families, access to a local community choir or music ensemble, group attendance at a local music festival or performance, and so on. At any of these, different identities and roles could be experienced, still in relation to one another: therapists might become accompanists, musical director, parents become MCs and co-performers, clients are audience members and performers, and so on. Also, the music therapy centre developed broader range of options including specialist music lessons; ongoing music session with large group involving parents, with ostensibly drop-in format becoming very regular and increasingly large because of such demand. Alongside, small music therapy groups continued, as did dyadic work, especially with those clients who couldn’t cope with larger groups. The on-site community choir provided additional musical access, which was inclusive of family members. JONES: How do you see the clients’ voice/perspective in relation to the research? PAVLICEVIC: We found this ethically problematic – especially given the paucity of clients’ voices in the literature. However, the parents were clear that the focus group discussions should be without the clients (their children) being present. This request made sense to us retrospectively, when the parents in one focus group especially, talked about their own sense of isolation and loneliness as a result of having a son or daughter with disability. Having their ‘child’ present would have prevented such a discussion. Through their long-term experiences of intimate musical inter-subjectivity in shared music therapy work with clients, the music therapists felt confdent in ensuring the representation in the study of ‘what the client would have said, known, thought, and said’. Their long-term relationships with the parents also amplifed the representation of clients’ experiences throughout the study. There was also a sense of trusting the combination of parents and professionals as advocates – like the therapists themselves – for clients who can’t speak for themselves. For the therapists, supervision ensured that they remained alert to own stance while listening to the client’s voice. We would posit that representation by others, however intimate, is always fltered; and that nothing replaces the direct presence of the person in the room. In that sense, this study remains unsatisfactory. JONES: Some position the relationships between therapist and client in relation to growth or empowerment, emphasising notions such as client agency. Looking back at the research and the fndings, how do you refect on the way the professionals and parents see the young clients – how they position the act of therapy and the role of client in terms of ‘need’ (2014: 12) and in terms of agency?

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The word ‘need’ presented a discursive dilemma throughout the study– since it counters our own frame of young persons with agency: who we experience in music therapy as empowered and resourced, while also living with a disability. At the start of the paper the SCOPE quote conveys that disability has much to do with the interfacing between the person and a maladapted environment, whereas for us, even within a music therapy centre, the word ‘need’ risked reducing the person to just that: someone who comes to therapy because of a need, a problem, a limitation, an exclusion. Parents and professionals in this study saw and experienced music therapy as a rich palette of multiple experiences on the needs–empowerment continuum, shifting at times towards music therapy fulflling need by working towards eliciting and enhancing individual potential, addressing crises, and helping to develop friendships, build social confdence, and so on. Need was never far from the surface though – which is linked powerfully to the professional ‘therapy’ discourse. Concurrently, contemporary government policy speaks of the need for independence (or agency) – which while making sense developmentally and socially, remains unattainable for many of the young adults featured in the study. The reality for parents and carers in everyday life, is that their sons or daughters need ongoing care and support, and are dependent on them for their daily living. We would encapsulate parents and carers’ positioning of music therapy as one of trust. Trust in music itself: as an enactment, experience and celebration of agency, even while in their own daily engagements with clients, they are constantly reminded of the young adults’ (at times severe) dependences. Parents and carers also increasingly trusted their own understanding that the musical relationships could both sustain and grow agency while concurrently working with need. This was increasingly understood (and explained) by them as thanks to being non-judgemental, non-verbal, inexact and fluid while also demanding of sustained engagement and commitment. Finally, the music therapy social scaffold which grew over the years of attending music therapy generated its own trust in the social–musical relationships – and this enabled the rich generation of shared meaning as part of the journey of this study.

PAVLICEVIC:

Pavlicevic and Ansdell have described Community Music Therapy as challenging the notion that music therapy and practice situates the music therapy space and relationship as a ‘culturally neutral’ place with a ‘seal between “inside” and “outside”’ (Pavlicevic and Ansdell, 2004: 37) and with the therapist being defned by a set of ‘neutral’ skills that can be ‘apparently’ transported from ‘one working/regional/socio-cultural/professional context to another, confdent that our skills apply everywhere’ (2004: 37). They argue that in the twenty-frst century ‘wherever we practise, we can no longer simply state that music therapy is “such a such” a practice, described with the help of “such and such” theories without addressing . . . context . . . context

290 Client–therapist relationship  needs to defne how music therapy happens, and how we think about it’ (2004: 45). Context in this situation means the physical, mental and social reality of the participants involve in the music, ‘not just the mental and social and musical reality of the music therapist working with the consensus model’ (2004: 45). One of the powerful elements of this research is that it was driven by the perception that the work which the arts therapist and clients were engaged in together was not matching established ways of thinking about the therapeutic relationship. New discoveries and insights are made about issues driven by the experience of arts therapy practice. The research summary and interview enables us to see how the approach discussed aims to create a sense of therapeutic relationship involving music that enables a more effective engagement with the ‘complexities of the clients lives and their relationship to their lived world’ as it ‘embraces families and social worlds, situations and contexts’ with ‘musical experiences and music-based relationships . . . beyond the therapist–client relationship’ (Pavlicevic et al., 2014: 17). The arts have been seen as linked to creative ways of attempting to solve or sort such differences, problems or barriers (Liebmann, 1996; Jones, 2007). Throughout this book the theme of the possibilities created by the contact between therapy and the arts is described in different ways. In this particular context, we have seen the ways in which the presence of the artist and the therapist roles together can produce new combinations and possibilities. For me, it is this that is radical, that allows exploration and new approaches to respond to the emerging needs of clients in many situations. As the research examples in this chapter illustrate, this can help to meet the challenges of new social, cultural or political needs.

Conclusion At the start of the last chapter I talked about the client and the therapist being in a ‘transaction’ together: the client playing an active role in whether change occurs. We’ve seen that in the arts therapies one of the key factors in the therapeutic relationship is that the client is invited to be actively creative within an artistic medium. This is central to the ways the client plays an active role in how change occurs. The engagement with the art form, whether music, drama, art or dance, creates opportunities for specifc processes, relationships and products to be brought into the therapeutic relationship and space. We have seen some of these opportunities illustrated and analysed: the therapist and client who move or paint together, creating artefacts such as a series of drum beats or a painting; the therapist who plays music to the client or who transforms themselves into a parent or an animal. These rules, artistic traditions and languages affect how the arts therapist behaves, and impact on the way a client experiences the therapeutic relationship. The last chapter also showed how the arts therapies have developed in response to other forms of therapy. We’ve seen how verbal language is only one way to articulate and create a relationship between therapist and client.



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The arts therapies offer a wide range of routes to discover and create contact between therapist and client. If this relationship is seen as key to therapeutic change, then the processes of creativity, learning and change that the arts therapies unite, provide a unique combination of languages. There are opportunities within the therapeutic relationship – a mutual discovery in the ways in which the artist within both therapist and client emerges. This chapter has shown that such combinations – of art form and creativity in the therapeutic space – create unique possibilities for change. As we’ve seen, then, the arts therapist and client together can inhabit a range of roles and paradigms within the arts therapy space. We’ve seen how the arts therapies can be involved in a dialogue with other therapeutic paradigms, particular ways of working, and opportunities for the client. We’ve also seen how the relationship involves specific qualities of the ‘artist’ within both the client and therapist. In addition, this chapter has illustrated how the process of mutual learning and discovery between client and therapist is a central feature in the healing and growth of the client. Running through much of this work is the notion that there are particular, innovative qualities within the arts therapies that are offered to the client. The next chapter looks at how the effectiveness of these qualities is examined, and how best to describe the unique opportunities for the client and therapist to work together.

seventeen

Effcacy: what works in the art gallery? What works in the clinic? Introduction For any client entering therapy, or for any organisation, parent or guardian considering the provision of arts therapies, the issue of effcacy is bound to surface. Do the arts therapies work? How do you know? What are the goals of the therapy? What will the outcome be? For the arts therapist also, similar questions are asked and are the focus of rich enquiry. The future development of the arts therapies depends on the answers to such questions. Increasingly, in a number of countries and healthcare systems, particular approaches to the defnition and ‘proof’ of effcacy are primary issues affecting provision, client or patient choice and funding. How clients, therapists and organisations evaluate and communicate the outcomes of the arts therapies has become especially important to research and enquiry. If clients, or organisations funding health services, are not satisfed that change is occurring in a way they understand, at a pace they fnd satisfactory or within a paradigm that they recognise, then the arts therapies will dwindle into abandonment as viable options in client care. In the UK, for example, Parry, in her description of evidence-based practice, cites the National Health Service’s explicit commitment: to drive policy, make commissioning decisions and allocate resources on the basis of research evidence on what is clinically effective and cost-effective. This includes assessing evidence of need for a service or an intervention (basically defined in terms of people’s capacity to benefit) and the measurable health gain for a given investment of revenue. (Parry, 2000: 61) In a much earlier reflection, from 1973, the developmental psychologist Gardner, in his writing about the arts and human development, said: Whilst it would be most promising to find that the arts can aid in the cure of psychological diseases, evidence on the question is most limited. Certainly the causal connection is in doubt: there is no way of determining whether an 292



 Efficacy 293 aesthetic breakthrough is a symptom or a cause of psychological development. (Gardner, 1973: 346)

His language and conceptual framework is bound within a different era, with its notions of ‘psychological diseases’, dating from a time when the professions of the arts therapies were establishing themselves in many countries. However, Gardner’s words – creating questions about the ‘promise’ of the arts and identifying tension between ‘evidence’ and ‘doubt’ – are still alive and resonant for the feld. Reviewing the situation a half-century later, is there any ‘proof’ of the effcacy of the arts therapies in ‘aiding’ or in ‘cure’, for example? Have we moved beyond Gardner’s sense of promise in the face of ambivalence and limited evidence? Approaches in the arts therapies range from the use of case study, based on careful individual accounts of therapy to large-scale Randomised Control Trials (RCT). This chapter will feature a variety of terms and concepts: there is not one way of defining or accounting for efficacy. It will look at wider contexts for therapeutic work as well as a variety of specific responses within the arts therapies. For example, the British Association for Counselling and Psychotherapy sees ‘efficacy’ in the following way: The types of research investigating the effects of therapy are often divided into 2 categories: efficacy research which studies therapy under strictly controlled experimental conditions, comparing the difference between control and intervention groups, and effectiveness research which investigates therapy in routine settings using pre- and postmeasures, but without a control group. (BACP, www.bacp.co.uk/research/ resources/index.php) Other perspectives are reflected by Regev and Cohen-Yatziv (2018) in their review of research and ‘effectiveness’ in art therapy. They draw on Hill et al.’s definition of the term effectiveness as ‘the attribute of an intervention or manoeuvre that results in more good than harm to those to whom it is offered’ (1979: 1203). Whilst focusing on quantitative perspectives, which include ‘symptoms and physical measures, health or mental health assessments’ (Regev and Cohen-Yatziv, 2018: 1531), they note that this is a partial response to the richness of art therapy. They cite, for example, detailed case study work as a means of understanding efficacy, concluding that: ‘there is no doubt that using a variety of research methods can help expand knowledge in the field’ (2018: 1531). One of the terms that has become common within much health provision is ‘evidence-based practice’, often linked to ‘evidence-based medicine’, defined as the ‘conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients’ (Sackett et al., 1996: 72). This has been adapted in a

294 Client–therapist relationship  variety of contexts, for example by Cook et al. (2017), defining ‘evidencebased practice (EPB) in therapy’ as: integrating the best-available research with clinical expertise in the context of the patient’s culture, individual characteristics, and personal preferences. The best research evidence refers to data from meta-analyses, randomised controlled trials, effectiveness studies . . . as well as information obtained from single-case reports, systematic case studies, qualitative and ethnographic research, and clinical observation. (Cook et al., 2017: 537–8) They situate an aim for this perspective as involving decisions about provision being made ‘collaboratively with the patient, based on the best available evidence, with attention to costs, benefts, available resources, and option’ (2017: 537–8). None of these descriptions are neutral: they highlight different perspectives on understanding or accounting for change. In many countries and contexts, the arts therapies, along with other therapeutic provision, are engaging with the impact of particular constructions of efficacy. The following responses illustrate the complexity of such engagement, based on research (Jones, 2013) into dramatherapists’ experiences in different countries: ‘The school requires information on the impact of dramatherapy on the children’s behaviour both in the classroom and the playground. They want to see behaviours that have significantly changed. They want to see evidence that the intervention has brought changes in the children’s ability to focus in class and the child’s ability to integrate more fully in the school day, be that within academic or nonacademic areas’ (Dramatherapist ‘C’ UK). ‘The organization that I work within is strongly CBT (Cognitive Behavioural Therapy) oriented (forensic psychiatry). Since CBT has a long history of evidence regarding effects of therapies/interventions, we as Arts Therapists, and I as Dramatherapist are supposed to ‘compete’ with that’ (Dramatherapist ‘E’ Netherlands). ‘Within our practice we are asked to provide evidence of the effectiveness of our practice, this is more so with all the recent changes (i.e. budget holders). Two standard measurements that are currently used are the SDQ (Strengths and Difficulties Questionnaire, www.sdqinfo. com) and Core (Child and Adolescent Mental Health



 Efficacy 295 Services outcome measures, www.corc.uk.net/resources/ measures)’ (Dramatherapist ‘M’ UK). (Jones, 2013: 145)

One aspect of this area, referred to by a number of respondents in this research, concerned the complexity of balancing different perspectives, which were experienced as being in tension: ‘It is hard to keep the voice of the client in the picture at times. Drama therapy, by its nature, aims to empower clients, to help them relocate themselves in their bodies, their voice. At a time when there is an increasing emphasis on externally set criteria to evaluate change, I find it hard to keep the client in the picture and this threatens the core of my beliefs about being an arts therapist’ (Dramatherapist ‘V’ Taiwan). (Jones, 2013: 145) These extracts illustrate some of the dynamics at work concerning therapeutic change being understood in particular ways. Here, for example, is an emphasis on ‘effect’ as evidenced by changed behaviours outside of the dramatherapy room, along with measurements which are developed outside the discipline of dramatherapy or having ‘long histories’ which dramatherapy is seen to ‘compete’ with. Issues such as the perspectives of clients and their ‘voice’ within an understanding of the efficacy of the arts therapies is also raised by the respondents in terms of a struggle to keep them ‘in the picture’. Therapists position evaluation of change as concerning power and belief: externally set criteria are seen as not easily engaging with client empowerment and therapist ‘beliefs’ about the importance of client ‘voice’. This chapter will explore such ideas, positioning the areas identified here such as paradigms of therapeutic change, efficacy and outcome as varied and contested by exploring different perspectives and contexts. There are different aspects of the therapeutic encounter that concern efficacy. These processes are common to much arts therapy practice, but their contexts vary from everyday procedures through to specialised large-scale research. These contexts include any initial assessment, the forming of aims and evaluation of work with clients undertaken as part of everyday arts therapy practices. Efficacy also embraces specific research-based projects where more formal procedures involve specialised monitoring, evaluation and communication through thesis or publication (Armstrong et al., 2016; D’Amico et al., 2015; Jaaniste et al. 2015). Authors have pointed to issues regarding the value of what is discovered within all of these processes, such as the difference between looking at ‘outcome research’ compared to looking at the ‘process of change’ (Wiser et al., 1996: 102), or the validity of a particular way of looking at change and outcome. Critical challenges have developed concerning the nature and impact of the various approaches to therapy and efficacy. Cornish (2013), for example, cites Timimi (2010) in

296 Client–therapist relationship  examining the position of art therapy in relation to child mental health provision in the UK. Timimi argues that the influence of a market-driven model of health provision reflects ‘neo-liberalism’s failings’ and how provision for children and families is being negatively ‘shaped, and conceptualised by economic, political and cultural pressures’ (Timimi, 2010: 686). Cornish contrasts the benefits of ‘longer-lasting benefits’ of ongoing art therapy for children (2013: 29–30) with Timimi’s description of much provision being subject to ‘McDonaldisation’, facilitating ‘the rapid growth of child psychiatric diagnosis and the tendency to deal with aberrant behaviour or emotions in children through technical – particularly pharmaceutical – interventions’ (Timimi, 2010: 686). These different aspects of efficacy will be explored in this chapter. A client, for example, comes out of one of a series of music therapy sessions feeling that something has changed, but that they can’t put whatever is happening into words: they are wondering whether to continue with the therapy. At this moment, they are making a choice based on their experience of therapy and their opinion about efficacy. A department of mental health, in conjunction with a university research faculty, undertakes research on the outcomes of dance movement therapy in a series of hospitals within a trust using a randomised control trial design. Their research may have funding implications for the future of the provision of the arts therapy in the trust and also wider implications for national and international knowledge and provision. Part of their research concerns whether, and how such outcomes can be reproduced elsewhere by other practitioners and clients. Clearly the needs and approaches for client and therapist are related but different in these two examples. For the client in the first example, questions around efficacy might include: how to make sense of what is occurring, whether the time, money and effort is having any of the effects they wanted when they went to therapy, or whether there are any unexpected effects they wish to pursue further. The music therapist in the first situation might be concerned with how to assist the client in gaining a perspective on what is occurring in the therapy, to review the progress of the work, and to empower them to make choices about the direction and provision of their therapy. Issues about the meaning of their feelings around continuing or finishing may also be explored. This could involve areas such as whether this reflects any patterns in their lives concerning attachment, for example. The work might explore whether the desire to terminate is based in unconscious resistance to areas surfacing within the therapy, or in a positive sense of readiness to move on or of the therapy not providing them with what they needed. For a client in the second example, some of the issues might be similar and contribute to the mutual discoveries between therapists, clients and departments about how effective the therapy is. For the therapists and researchers, similar concerns are present regarding the progress of the client. In addition, the evaluation of how effective the therapy has been gives an understanding that will contribute to others within the field, and to the continuity of the provision at the setting. Any insights into how change has happened will also assist in looking at whether, and how, the specific practice is developing, and

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in finding a language to help reflect upon and communicate the processes and effects of the arts therapy. The common aspect, in both of these examples and in every piece of work that takes place, from private therapy session to more formal research, is that the area of efficacy plays a crucial role in all arts therapies practice. Some would see a continuum existing between the informal and formal procedures in everyday clinical practice and formal clinical research projects. Others, as we will see, might argue that they are separate and have very different values. Taylor (1998) usefully defines research in a way that embraces these concerns: The term ‘research’ refers not only to quantitative, scientific regimes, but . . . also encompasses a wide variety of methods and depths of analysis. It could range from a short interview to an experimental set-up in a laboratory. Analyses might involve the use of text transcription, percentages or sophisticated statistical interpretation. Whatever the method and depth of analysis adopted, the important thing to remember at all times is the appropriateness of [the] strategy used. (Taylor, 1998: 204) Looked at in this way, research into effcacy helps inform the creation of a dialogue, or language, between therapist and client about the progress and outcome of their work. As we will see, fndings from new research continue to inform this dialogue.

What works in the art gallery? What works in the clinic? Much contemporary writing about how to look at change in the arts therapies features a consideration of the relationship between the arts and sciences (Byrne, 1995; Erkkilä, 1997; Jones, 2013; Warth et al., 2015). As noted earlier in this book, at times this relationship is one of mutuality, at others of extreme difference, and still others one of creative tension. Sometimes all three of these qualities can be present at the same time. However, as Chapter 10 discussed, the relationship between art and science is complex and, in many cultures, one marked both by division and by opportunity for innovation and mutual discovery. The ways in which effcacy is positioned by the arts therapies in relation to this relationship is not simply concerning how to evaluate practice, it is connected to identity. This is highlighted in the following statement from a research article about music therapy: As clinician/scientists, it is advisable to be informed, ask questions, and be curious and passionate about honing our expertise, understanding what we know and what we do

298 Client–therapist relationship  not know, and drawing upon the best evidence available to inform practice. Music therapists are encouraged to become informed critical consumers of systematic reviews, meta-analyses, and other evidence-based review reports. (Else and Wheeler, 2010: 46) Here there is no mention of the therapist holding an identity as an artist at the same time as scientist. The authors do not use the word ‘arts’ or ‘artist’, ‘creative’ or ‘creativity’ in their whole article and this can help as a provocation to enable us to reflect on the identity of the arts therapist in relation to their work and its effects. The first sentence in the quotation, for example, could have argued for the role of artist also being one that involves being ‘curious’ and ‘passionate’ about expertise. However, the only identity mentioned is that of ‘clinician/scientist’ and as a ‘consumer’, not of the artist, nor of artistic experimentation and innovation to deepen music therapists’ craft expertise: we have ‘systematic reviews, meta-analyses, and other evidence-based review reports’ (Else and Wheeler, 2010: 46) This quotation is a testimony to a particular tension: the implication is that the arts therapist has a particular kind of clinical-scientific identity and Else and Wheeler make revealing choices about what they include or foreground and what they deliberately, or unconsciously, leave out. Music therapist Aldridge (1996) talks about two very different approaches to ‘science’. One concerns the development of precise, fixed procedures ‘that yield a stable and fixed empirical content’ (1996: 90), such as controlled trial methods. The other depends on ‘careful and imaginative life studies’ which may lack some of the ‘precision of technical instruments’ but continue a close relationship with what he calls ‘the natural social world of people’ (1996: 90). Hughes et al. argue that mess, creativity and improvisation mean that researchers, and those being researched, need to be able to meet and capture ‘experiences that confound expectations of an orderly, rule bound . . . universe’ (2011: 188). They, for example, argue that the researcher needs to be able to improvise, to be flexible and open to events that unfold, and that too much ‘predetermined design’ (2011: 188) of tools hinder the richness and efficacy of the research in its enquiry into arts processes. The arts therapies have made a strong case for the role of qualitative research in looking at change and outcome (Payne, 1993). Many also make use of a combination of research approaches. McNiff, for example, discusses the use of art-based outcomes for art therapy. This involves looking at ‘changes in the content of artistic expression, changes in the “quality” of expression, increased spontaneity, greater persistence in the making of art, and fluctuations in the aesthetic satisfaction of both client and therapist’ (McNiff, 1998: 203). Another approach in art therapy, for example, concerns evidence based on images. This centres on looking at art work and ascribing meaning to it – here parallels are assumed between thought patterns, feelings, behaviours and images made. The creation of images is considered to reflect changes in



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inner processes, experiences conscious or unconscious and the relationship with the therapist. However, some have made the point that: Unconscious defence mechanisms and conscious resistances all operating to shield the conscious from anxiety provoking ideas, tend to make very risky the assumption that a drawing is a direct representation of a patient’s concerns or feelings . . . [it is necessary to] go beyond the manifest content . . . peruse it for clues about areas that the patient could not or would not reveal. (Feder and Feder, 1998: 262) The role of the therapist here is to act with the client to make suggestions, invitations to explore and connect areas of the painting within the relationship. Some have argued that as dramatherapy is ‘rooted’ in an art form, its methods of understanding efficacy have, mainly, reached to the qualitative paradigm. Landy’s review of the momentum of enquiry and understandings of efficacy in dramatherapy, for example, notes that, ‘it seems clear that drama therapists, as well as other creative arts therapists, have turned to more qualitative approaches, to newer research paradigms as appropriate to their search for meaning within the creative, therapeutic process’ (Landy, 2001: 10). He has argued that dramatherapy, though ‘an interdisciplinary art and science is more essentially an art . . . its primary method of investigation should be an artistic one’ (1994: 254). He allies this paradigm to his own research ‘centred . . . firmly in the art form’ (2001: 11). Music therapist Hoskyns has said, for example, that the ‘art/science dichotomy seems to be our biggest hurdle in developing effective research. We fear that we will lose the meaning of the art by evolving strategies for research’ (Hoskyns, 1982). Dramatherapist Milioni (2001) has talked of this issue in terms of a division between a social constructionist way of working and an empiricist way of approaching change. The social constructionist approach she typifies as relativist, emphasising a reality that is ‘elusive, everchanging’ (2001: 10). Empiricist research is based in knowledge emphasising ideas of objectivity and value-free judgement. The second position she allies with contemporary attitudes to evidence-based practice and clinical effectiveness, the former with ‘freedom and flexibility’ (2001: 10–11). Can the arts and sciences both be used to help understand efficacy in the arts therapies? Some would argue that ways of looking at what works, what is effective in the arts and ways of looking in the sciences have no common ground. If I try to judge whether an artist or art work is being effective, do I use very different processes than if I try to establish whether a cognitive behavioural therapy process has helped in making a difference in a client’s life? Are the contexts of theatre or art gallery and clinic so different that ‘what works’ in each can’t find a mutual connection? Or can the arts therapies draw on discoveries and processes from each area?

300 Client–therapist relationship  In the arts, efficacy often concerns itself with aesthetic questions of debate and the idea that there is not necessarily a correct answer to whether an art work is ‘effective’. What is meant by efficacy in the arts within some societies, or sections of societies, and in different eras has been governed by strict orthodoxy. At other times, though, and for many artists and arts movements described in this book, the nature of how and whether work is effective is the subject of constant debate, argument and re-evaluation. The effectiveness of the arts is an extremely contested, volatile and mutable subject. At any one time there can be a number of conflicting variations on what is valuable, what ‘works’ as art. In addition the situation of the postmodern centres around diversity of meaning: ‘Something has changed, and the Faustian, Promethean (perhaps Oedipal) period of production and consumption gives way to the “proteinic” era of networks, to the narcissistic and protean era of connections, contact, contiguity, feedback and generalised interface that goes with the universe of communication’ (Baudrillard, 1983: 126). Different individuals or groups, different makers, participants and consumers or audiences involved in the arts can all have different views on efficacy in this ‘universe of communication’. It is possible to say that the redefinition and constant re-evaluation of efficacy is one of the keys to much contemporary artistic creativity: a time where meaning in the arts is typified by ‘profusion and openness, process and struggle’ (Cubitt, 1993: 206). I would argue that efficacy is at its most alive when it is part of the creative process, a dialogue between all those involved: the makers, participants, audiences and critics. It is brought vitally into every moment and is a crucial part of the experience of all those involved – it engages them in what is happening, affecting their experiences of the encounter. It is mutable, debatable; and this fuels the development of the art form and those involved in it.

Approaches, contexts and efficacy The following offers two different perspectives to illustrate these dynamics within the arts therapies: the Cochrane Review and Case Study approaches to engaging with effcacy. In areas relating to science and health, concerns about ‘what works’ have often been to do with observable outcomes, reliability and replicability. Barkham and Mellor-Clark, for example, say that ‘a central axiom of the scientific method has been replication’ (2000: 129). Within medicine, for example, research that is formed by particular approaches to quantitative enquiry is seen as the ‘gold standard’ in efficacy (Savin-Baden and Howell Major, 2013). Illustrations of the rise of this paradigm can be seen within the increase in randomised control trials (RCT) and ‘Cochrane Reviews’ within the arts therapies. Greenhalgh et al. summarise the ‘defining characteristic of a systematic review in the Cochrane sense’ as involving ‘the use of a predetermined structured method to search, screen, select, appraise and summarise study findings to answer narrowly focused research’; the Cochrane framework situates a ‘systematic review’ as a ‘summary of the



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results of available carefully designed healthcare studies (controlled trials) and provides a high level of evidence on the effectiveness of healthcare interventions’ (2018: 3). An example of a Cochrane review is that of Aalbers et al. (2017) with its objective to ‘assess the effects of music therapy for depression in people of any age’. The reviewers searched databases such as the Cochrane Common Mental Disorders Controlled Trials Register or the Cumulative Index to Nursing and Allied Health Literature (CINAHL), examining through ‘meta-analysis’, randomised control trials (RCTs) and controlled clinical trials (CCTs), comparing music therapy versus ‘treatment as usual’ (TAU), psychological therapies, pharmacological therapies, other therapies, or different forms of music therapy for reducing depression. In their review they considered nine studies involving a total of 421 participants. The conclusion of their analysis indicated ‘that music therapy provides short-term beneficial effects for people with depression. Music therapy added to treatment as usual (TAU) seems to improve depressive symptoms compared with TAU alone’. Additionally, they conclude that ‘music therapy plus TAU is not associated with more or fewer adverse events than TAU alone. Music therapy also shows efficacy in decreasing anxiety levels and improving functioning of depressed individuals’ (2017). Though some health systems give the impression that such an approach is a ‘given’, this is not a neutral perspective on the provision of therapy: terms and concepts referred to by Parry and reflected in Aalbers et al.’s review, such as ‘evidence’, ‘benefit’ and ‘measurable health gain’, have been, and are still, contested and much debated. Greenhalgh et al., for example, argue that such an approach is partial and decontextualised, with its ‘highly technical’ and prescriptive approach to what can be counted as evidence, and they argue that it is too removed from the nuanced complexity of the actual lived reality of health work: ‘the doctor in the clinic, the nurse on the ward or the social worker in the community will encounter patients with a wide diversity of health states, cultural backgrounds, illnesses, sufferings and resources’ (2018: 1). Writers such as Higgins (1993), Gilroy (1996), Edwards (1999) and Grainger (1999) have examined the case study as an approach to looking at efficacy. Gilroy and Lee (1995) have pointed out that the case study can reflect different approaches to understanding outcomes and change. The case study might be based on a descriptive account, or it might be part of a collaborative enquiry where clients are involved in describing their experiences as part of the case study (McClelland, 1993), for example. Schaverien (1995) has said that a typical art therapy case study is based on the pictures and art objects of the client. The pattern of the case study often takes the form of: a description of the theoretical underpinning for the approach taken; a description of the setting and the client and any diagnostic material; along with a description of the arts therapy process. The case study approach has been seen as too subjective to contribute to research, ‘too “personal” . . . too untrustworthy, to be considered as reliable evidence of clinical effectiveness’ (Edwards, 1999: 6). Edwards points out the ‘healthy scepticism’ needed when reading some accounts within art therapy and

302 Client–therapist relationship  psychotherapy literature. He advocates a ‘rigorous . . . creative’ approach to case study. This emphasises the way in which the case study can pay attention to the individuality of the client and the difficulties they bring to therapy and how these are communicated through images, words and actions. He says that it engages with what he calls ‘the richness, diversity, messiness and complexity of the therapeutic process and lived experience’ (Edwards, 1999: 6). Attention has been given to the notion of the ‘stories’ within clinical work: ‘The process of counselling and psychotherapy is one that, in the end, relies on the telling of stories. Stories, about events, recent or long past, in the client’s life’ (McLeod, 1999: 173). In this way the case study becomes allied to story. The arts therapy session becomes a part of this process where the client’s ‘narrative’ becomes allied to image making, or music making, for example. The therapy becomes a way of exploring: ‘It is unhelpful to assume the stories these case studies tell are any less truthful than those that depend on purportedly objective telling’ (Edwards, 1999: 7). The case study, then, is seen as a form that can embrace the specific situation of the client and adapt to reflect the complexity of communication, the relationship between client, therapist and art form within the session and the client’s life. Edwards also says that the case study does not turn ‘people’ into ‘objects’, and offers the opportunity to respond to the immediacy of the experience rather than fitting the experience to previously proposed theories or explanations. The case study is also seen to be inclusive and contains the voice of client and therapist. The relationships between such particular approaches to efficacy and the funding of provision of the arts therapies in state medical provision or education is a theme within much recent literature, with the move towards evidence-based judgements connected to continuity of resourcing services. Warth et al., for example, note that ‘stakeholders and decision-makers within the health-care system . . . rely vastly on the results of controlled clinical trials to determine evidence based practice’ (2015: 366). However, a parallel phenomenon of diversity exists. This, too, concerns audiences, methods and intense debates about what efficacy means and what evidence is. Who, for example, takes part in deciding what ‘effective’ means? What are the tools and languages used to try to find out what is happening in the therapy? As reflected in the introduction to this chapter, recent literature has indicated a shift and a challenge to the field, as contexts such as schools and hospitals in many countries are demanding ‘proof’ of the impact of therapy connected to particular understandings and practices of ‘evidence’ (Jones, 2013; Leigh et al., 2012). Karkou reviewed patterns in arts therapies work in education contexts such as schools in a number of countries and notes that ‘in recent years . . . evidence-based education has become an important characteristic’ of the school environment (2010: 14), describing the current situation as forming a shift and a challenge ‘for arts therapists to develop ways of working that are tailored around the school culture’ of monitoring of performance and academic outputs (2010: 279). McFerran and Stephenson note the ‘spread’ of ‘evidence-based practice (EBP) . . . through . . . education’, and distinguish ‘interventions supported by “evidence” from “popular” practice, that is, interventions that are widely supported by schools but not founded



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on empirical research’ (2010: 259–60). Authors such as Shine analyse tensions between government-initiated demands and therapeutic provision in schools, in terms of: ‘the various professionals and agencies involved do not share a professional language or culture. Subsequently different emphasis is placed upon monitoring and achievement of outcomes’ (2012: 59). Shine argues for a ‘new approach’ to areas such as researching the effect of arts therapies in order to meet tensions arising in relation to the divide between ‘the demands’ of a therapeutic agenda to meet children’s emotional and psychological needs and educational settings dominated by the impact of therapy constructed within agendas of academic attainment (2012: 59). The ways in which environmental, social, political and cultural background create dialogues with the arts therapies is crucial in considering concepts and practices concerning ‘efficacy or ‘outcome’. Recent thinking has concerned different kinds of knowledge in relation to efficacy, concerning for example ‘traditional medicine’ described by Abdullahi as ‘variously known as ethno-medicine, folk medicine, native healing’ (2011: 115), citing the position of such knowledge within the World Health Organisation definition of traditional medicine as, ‘the sum total of the knowledge, skills and practices based on the theories, beliefs and experiences indigenous to different cultures, whether explicable or not, used in the maintenance of health, as well as in the prevention, diagnosis, improvement or treatment of physical and mental illnesses’ (Abdullahi, 2002b: 1). A traditional healer is defined there as ‘a person who is recognised by the community where he or she lives as someone competent to provide health care by using plant, animal and mineral substances and other methods based on social, cultural and religious practices’ (Abdullahi, 2002a: 11). Practitioners such as art therapist Mauro have pointed out that, in many situations, ‘assessments, interventions and programming of services have been developed to serve the American middle class, hence procuring a “cultural blindness”. This is a form of institutional racism’ (Mauro, 1998: 135). She goes on to add that culture will affect the way someone perceives changes and psychological factors which influence the way the person ‘acts out’ their mental illness and responds to treatment, observing that Hispanic families, for example, tend to attribute psychiatric illness to physical deficiencies such as general bodily weakness. Such commentary needs to be considered carefully in the light of the ways it may essentialise or generalise, rather than acknowledge contextual variation and differences within a culture. Arts therapists have explored issues relating to power and values within the areas of assessment, evaluation and efficacy. Joyce, for example, looks at the ways in which women have been oppressed by medical criteria and diagnosis (1997: 88), while Campbell and Abra Gaga (1997) look at women’s experiences of therapy in relation to sexism and racism. They stress the importance of the ideas of social constructivism in considering change within the arts therapies. Rather than imposing existing criteria and meaning on the client as ‘object’, the ‘therapist engages with the client in order to allow the narrative/story to unfold. This is from a position of “not knowing” whereby the client is viewed as “the expert”’(Campbell and Abra Gaga, 1997: 220).

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What is looked at and who is looking? Valente and Fontana have rightly said that there are dangers in therapists imposing on clients their own ‘interpretations of what it means to be “a psychologically whole person”’ (1997: 17). They say that in the arts therapies feld as a whole there is acceptance that there are a wide range of cues that can be used to monitor client progress and that there can be a wide range of outcomes. Their research explored how dramatherapists frame or understand the ways clients communicate their notion of improved well-being: a variety of ways to ‘answer the question “Is your client getting any better?”’ (1997: 29). They list broadly the outcomes involved, and consider the following as ways of evaluating change: Observation of client behaviours Client self reports Reports from other professionals Projective techniques Clients’ use of diagnostic dramatherapy media Reports by other group members Kelly’s repertory grid. (Valente and Fontana, 1997) Studies have looked at whether some particular characteristics are mentioned more than others in describing the outcomes of therapy, the changes for clients coming to the arts therapies. A survey identified what was looked for in assessing client progress in dramatherapy. It was intended to highlight the qualities that practitioners felt were ‘most amenable to development by dramatherapy’. These were the areas most cited by practitioners: Self-esteem Self-awareness Self-acceptance Self-confidence Hope Communication Trust Self–other awareness Spontaneity Social interaction. (Valente and Fontana, 1997) Valente and Fontana comment on the cluster at the top of the list to do with self-esteem, self-awareness, self-acceptance and self-confidence, concluding that there can ‘hardly be a more graphic illustration of the power for psychological change of the dramatic experience’ (1997: 26).



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Feder and Feder’s analysis of music therapy literature points to a different range of outcomes. These are: Breaking social isolation Stimulation of motor and perceptual activity Development of appropriate mechanics of behaviour control Reduction of anxiety states. (Feder and Feder, 1998: 319) Pavlicevic et al. (2014) offer a critique of the discourse around such framing of efficacy in the arts therapies. This concerns the absence of client perspectives: ‘the voices of individuals with severe learning disabilities [SLDs] are rarely heard. Generally, literature portrays the voices of music therapists, government policymakers (and through them, those with whom they have consulted)’ (2014: 8). They argue that this needs to be addressed: accessing and including in any articulation of efficacy the expressions and ‘understandings of young adults with SLDs’ experiences of music therapy and of how music therapy might address their needs’ (2014: 8). Wood (2013) parallels this, indicating the need for more research into client perspectives and views on the impact of the arts therapies. She argues that ‘therapists can learn from what is experienced as useful’ and asserts that ‘a response to the voice of the people who use services is growing in art therapy literature . . . the voice of people who use services is rightly a major consideration in framing research. Art therapy research might usefully develop existing collaborative approaches’ (Wood, 2013: 95). Jaaniste (2008) in her work with people with co-morbid substance misuse and mental health disorders in Australia talks both about a combined perspective and the complexity of enabling clients to find a language for the effect of their therapy. She sees the creation of such ‘understanding’ and dialogue as part of the therapist’s work: It is important to try to define efficacy and success, in the dramatherapist’s own terms as well as in the participant’s terms. For the dramatherapist, it was essential to work with the person to assist them to find meaning in the work they were doing in the group. Often, there is a sense that something has changed, but it is difficult to identify what has changed. If this work was to be successful in our terms, the participants would need to have a mental picture of what was happening in the therapeutic transactions and to explore areas of their lives which gave them a more explicit understanding of themselves, and to find the words to express this understanding. It is part of the therapist’s role to assist the client to find meaning in what is happening in the therapy and to empower them to make decisions and choices about the direction and goals of the therapeutic process (Jones, 2005). (Jaaniste, 2008: 18)

306 Client–therapist relationship  Bunt et al. (2000) in their practice with residents of a cancer help centre in Bristol, England, looked at the outcomes of a music therapy group which emphasised relaxation and social interaction. The settings’ aims were to help residents learn how they, themselves, could improve the quality of their lives and to influence the outcome of their illness. The programme emphasised the relationship between ‘whole mind, body and spirit’ (Bunt et al., 2000: 62). Focus groups of residents were offered opportunities to discuss and evaluate their experience of the music provision at the setting. Their evaluative comments were in their ‘own’ language and included: ‘The change of mood within the music had a ‘knock-on’ effect (listening)’ ‘Emotional at times with welling-up of tears and sadness (listening)’ ‘Felt fresher after the playing experience’ ‘The playing was powerful and releasing’ ‘Felt energised and creative in the playing session, good to participate with others’ ‘Playing session was more fun eliciting lots of laughter’ ‘Listening experience was lovely and calming, feeling happier and more energised after the playing’. (Bunt et al., 2000: 62) It’s interesting to note the less technical language here compared with the arts therapist perspectives gathered by Valente and Fontana (1997) – indicating, perhaps, the danger of creating different languages of efficacy, with one for the therapists or professionals, and another for clients or users. This could mean that it is hard to build commonalities in perception or dialogues about efficacy, for example. Valente and Fontana parallel areas of concern in their research outcomes with Maslow’s criteria: emotional openness, perception, spontaneity, self- and self–other acceptance and creativity. The clients working with Bunt et al. seem to combine a mixture of enjoyment of the act of listening and playing, of fun and laughter, of being calm and fresh. I include these to emphasise the ways that perceptions and languages of efficacy are framed by different contexts, by different therapists and clients.

The arts therapies and efficacy: flying with two wings? This introductory section has shown the complexities and diversity of frameworks concerning the concept of effcacy of the arts therapies. As we have seen, different positions exist concerning this: some argue for engagement that tries to achieve an ‘objective’ stance – an empirical approach, for example, using quantitative data that needs to be gathered. Others have argued that this way of gathering information is not valid, especially within a discipline that involves the nuanced complexities of arts processes, along with the diversity of phenomena that occur between therapist and client or clients within therapeutic work. We have also seen how the issue of effcacy



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is crucial to arts therapies practice. This includes processes which aim to empower any client to make decisions based on the progress of their participation in relation to the continuation or termination of therapy. It also includes arts therapists and clients working to fnd a language to understand and communicate change to deepen the feld’s knowledge of the effects of its work and to communicate to those making decisions about allocating scarce funding resources to provision, based on whether the arts therapies can be seen to be effective for those accessing their services. Tensions are pointed out by a number of practitioners and researchers between what can and cannot be known and expressed or communicated. Conquergood, for example, in his writing on ‘Performance Studies Interventions and Radical Research’ (2002), differentiates between ‘the dominant way of knowing in the academy . . . of empirical observation and critical analysis from a distanced perspective . . . a view from above the object of inquiry: knowledge that is anchored in paradigm and secured in print’, and ‘another way of knowing that is grounded in active, intimate, co-experienced, hands-on participation and personal connection’ (2002: 146). The first, he argues, has been pre-eminent, ‘marching under the banner of science and reason’, and having the effect of disqualifying and repressing other ways of knowing, ‘such as those rooted in embodied experience, morality and local contingencies’ (2002: 146). Haraway has echoed this, contrasting these two different ‘ways’ from a perspective that is interesting for arts therapists to think about: the ‘view from above’ being the first and the ‘view from a body’ being the second (Haraway, 1991: 196). McNiff talks about a ‘gap’ between what ‘can and cannot’ be known in a similar way: Creative arts therapy is engaged with both aspects of experience, and this clearly distinguishes our practices from disciplines which base themselves on totally predictable outcomes. As an art therapist I recognise the value of science and its research methods; but they can never encapsulate the totality of what I do. (McNiff, 1998: 31) He uses the image of flying with one wing, and stresses the need to address arts-based approaches to understanding outcome and change. He says that a particular vision of the world is always linked to any research activity – and that it’s important to ask: what view of the world does the approach to understanding outcome represent? I think such a division between art and science is too stark – the existence of disciplines such as the arts therapies challenge such dichotomies between ‘objective’ and ‘subjective’ experience. Some would argue that the identification of the subjective with arts and objective with science is too simplistic. The cultural tensions that these views represent, though, are a part of what the arts therapist inherits in many attitudes towards efficacy. The deep potential of the arts therapies’ relationship to efficacy is the

308 Client–therapist relationship  bringing of these apparently different worlds together as an opportunity rather than an impossibility. A number of the approaches described in this chapter try to achieve the task of flying with both wings – of bringing together art and science. This is a crucial part of the identity and nature of arts therapy practice, as important in efficacy as elsewhere. It is a unique, complex and challenging task – one to which, as we will see, there are a number of creative and challenging answers. What is evidence for the arts therapies, then? Put at its simplest, in any form of intervention with therapeutic change as an intended outcome, it is important to see what has occurred. This matters for a variety of reasons. On the level of much client-arts therapist practice, these include: • • • • • • • •

For the client to gain a sense of whether any change has occurred To inform client choice in making any decisions about which therapy may be appropriate for them To identify whether specific approaches or methods are particularly useful in intervention in specific circumstances For the therapist to try to perceive and understand what is happening – whether, for example, the work is having any effect For clients, therapists and organisations to see if there has been any outcome in order to offer the therapy to others To know when to stop To see what has occurred in order to improve the provision In some circumstances, to deal with issues to do with whether one therapy is seen as more ‘cost-effective’ than another.

At a more formal level, there are numerous research-oriented projects that attempt to look at areas of change with a greater degree of detailed analysis of the processes at work. My point is that all work, from the questions asked by clients within sessions, to in-depth case study or RCTs, is related by the core questions of whether, and how, the arts therapies have effect. These can be seen as part of an investigative project which all participating in the arts therapies are involved in. The next section looks at some of the ways this vital ‘project’ is taking shape.

The arts therapies: a range of encounters There are, then, different emphases within the arts therapies in dealing with effcacy. It is not as if there is one approach that dominates the arts therapies as a whole, nor even a single approach within one modality such as art therapy or music therapy. This, in my opinion, would not be desirable. The range of the conditions and situations that clients bring to arts therapy needs to be met as closely as possible by the most appropriate ways of understanding effcacy. The diversity that we are about to encounter is not a refection of chaos within the feld’s attempt to fnd one strategy, but rather a sign of the diversity of experience, and fexibility of approach and potential in the arts therapies.

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A part of this variety concerns the framework, or the therapeutic emphasis of the arts therapy. Hence, those practising within a behavioural or analytic framework will draw upon approaches and methods that give them information useful to their approach. As we will see later in this chapter, Example 2 draws on information about the client’s relationship with paintings and the art therapist, whereas Example 4 looks towards behavioural indicators such as social interaction and gesture. Another part of this diversity is reflected in the focus of the approach taken to evaluate efficacy. This concerns the way of looking, what is used to give information. This in turn relates to the methods chosen. Within all these areas the key question for me is how the meaning of efficacy emerges as a part of a dialogue. This is between therapist, client and, where appropriate, the paradigm of the service or organisation they are working within. It concerns how framework, focus and method come together in a way that is meaningful for client and therapist.

Ways of working: considering the effects of the arts therapies A rich and varied culture has emerged, then, concerning understanding and communicating effcacy, whether in the framework, focus or method chosen. This chapter will now examine some examples that give a favour of the diversity of approaches. It will also look at the ways in which dialogues with other disciplines have taken place, as well as some of the new discoveries the arts therapies are making about effcacy.

Example 1: Client voice and an ecosystemic approach Focus on Research Interview with Kim Dunphy and Tessa Hens This interview relates to Dunphy and Hens’ (2018) innovative work exploring the potentials of an iPad app, ‘MARA’ (Movement Assessment and Reporting App) to access, include and respond to client voice within assessment and evaluation. The specific example of research concerns sixteen adult participants with intellectual disabilities (ID) attending dance movement therapy. The clients were part of research into the app. Dunphy and Hens’ practices are framed by them as being within an ‘ecosystemic’ approach: This approach views therapeutic interventions as being significantly influenced by interactions between individuals

310 Client–therapist relationship  and their social networks. Because of the communication challenges and other barriers people with ID face, meaningful goal setting, and responsive assessment requires effective collaboration between therapists, participants, their families, carers, and other stakeholders. (Dunphy and Hens, 2018: 3) The researchers contextualise client ‘voice’ and concepts of outcomes in dance movement therapy by identifying theoretical and policy drivers for progress and new demands or needs in understanding and accounting for therapeutic change. These are drawn from a variety of interconnected perspectives. An important aspect of their innovation is articulated as a response to the shifting climate of care in Australia where, ‘new approaches to service delivery, such as the National Disability Insurance Scheme (NDIS) . . . require outcome-focused reporting that is responsive to the perspectives of clients’ (Dunphy and Hens, 2018: 2). Another driver identified by them concerns empowerment and voice, connected to Australia being a signatory to the United Nations Convention on the Rights of Persons with Disabilities (United Nations Division for Social Policy and Development, 2008). The impetus of the Convention requires service providers to recognise individuals with disabilities’ participation rights by placing them and their families or carers at the centre of decision making related to any provision, such as therapy. This sees ideas and practices concerning the understanding and communicating of the ‘effects’ of the arts therapies in terms of client-led choice making and self-advocacy, rather than clients ‘being passive recipients of care or treatment’ (Dunphy and Hens, 2018: 2). Another facet concerns the particular potentials of arts forms and processes involved in dance movement, combined with the opportunities of new media, to respond to these drivers for change. The complexities of creating such new routes to understanding and accounting for change are seen in terms of opportunity and challenge. Dunphy and Hens note that, along with many other professionals involved in health, education and care provision, ‘dance movement therapists face particular difficulties in this respect, as they have few assessment tools that are practical for regular use. Existing dance movement therapy assessment approaches largely do not yet prioritize input from clients’ (2018: 1). Other challenges are noted by them in relation to creating meaningful opportunities for the expression of views of people with learning difficulties, where the impact of ‘low societal expectations around their ability to self advocate’ can hinder ‘confidence, and (their) capacity to share opinions’ (2018: 2). The approach aims to offer client-centred ways to facilitate reflection on progress in response to ‘challenges with communication, recall, generalization, and abstract thinking’ for the individuals with learning disabilities in the group (2018: 2). The research explores the potentials of diverse, creative methods to access client-participant voices as part of a matrix of perspectives which aim to understand, support and



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create dialogue between participant/clients, dance movement therapist/s, other professionals and parent or guardians. They use the term ‘stakeholders’ to reflect the commonality of these different roles, as they are all seen to have the potential to contribute to each client’s ‘development and progress’ (2018: 1). The app, MARA, is informed by an ‘Outcomes Framework for Dance Movement Therapy’, created specifically for such engagement with assessment, with ‘outcomes structured across five domains: physical, intrapersonal/ emotional, cultural, cognitive, and interpersonal’ (Dunphy and Mullane, 2018). It enables the recording and exporting of data in multiple formats such as numerical graphs, written notes, photos, and videos and enables a mosaic of perspectives from therapist and client. Within this variety, the following description of evaluation focuses on the app as a part of the process of engaging the client-participants in expressing, communicating and reflecting on their experience of the dance movement therapy and its role in involving clients in ways that have not been part of established practices.

Illustrative example In one-to-one interviews, accompanying the group therapy, each participant views photos and short videos of themselves taken during sessions. The therapist-researcher works with each person to refect on their experiences in the dance movement therapy sessions. Images and videos are engaged with using a client-led choice to use words, movement, gesture symbols and visual aids to facilitate and record their perceptions about the therapy and of their own progress. The app provides a way of both recording their input and also becomes a part of the refections made, along with those by the therapist on the therapy. The following is an example of the interaction with one of the client participants, Angela. The therapist-researcher and Angela view short videos and photos of her experience of the sessions captured in the images, with the therapist asking Angela about the app material: A: ‘Movement, dancing’ ‘I learned about my spine.’ ‘Hand movements; relaxation’ ‘I was having fun watching myself. I liked looking at pictures of myself’ ‘Good to see myself happy. That feels good. I’m enjoying it’. (https://www.frontiersin.org/articles/10.3389/ fpsyg.2018.02067/full#supplementary-material) Whilst reporting that engaging in reflection about progress over time was challenging, the researchers report on the ways the app enabled client participation. It enabled the participant-clients to reflect on their experience through

312 Client–therapist relationship  the images and assisted dialogue between therapist and client about the clients’ perspectives of their experiences. In addition, the app enabled the recording of the commentary by clients, and this was included within the reflection and evaluation of the impact of the work enabling this to be dialogic. JONES:

You make the important point that ‘existing dance movement therapy assessment approaches largely do not yet prioritize input from clients’ (2018: 1). Why do you think client voice has been so little attended to in the evaluation of the arts therapies or in our understanding of their effcacy? DUNPHY AND HENS: We respond with informed expertise on assessment in DMT only. These same issues may impact assessment in other arts therapies, but we can’t claim informed expertise in other modalities. At this point in the development of the DMT profession and its practice, assessment of all forms is signifcantly underdeveloped. Barriers in dance movement therapists’ capacity to provide evidence-based assessment of their programmes include availability of frameworks that adequately describe observable movement (Powell, 2008); dance movement therapists’ preferences for informal assessment measures which negate a systematic approach (Powell, 2008); and the dearth of user-friendly comprehensive assessment frameworks (Cruz and Koch, 2012; Powell, 2008) especially those that provide data relevant for both therapists and other stakeholders, including clients themselves (Snow and D’Amico, 2009). Use of specialist jargon, such as Laban Movement Analysis, contributes to the professionalism of dance movement therapy practice and the capacity for practitioners to have detailed and shared understandings. At the same time, it can limit lay-persons’ (especially clients but also family/carers and other staff) capacity to contribute to the assessment process. One well-known tool for dance movement therapy assessment, the Kestenberg Movement Profle requires such a high level of specialist expertise that its potential even for use by DM therapists is limited (Koch et al., 2001). In addition, the historically prevalent medical models of health and service provision that have influenced creative arts therapies to date have not as yet predicated clients’ perspectives of their own progress at least equally with that of practitioners. Such models cast those with disabilities, for example, in roles of passive recipients of care or charity, with disability being viewed as a cause of conditions requiring ‘curing’ or ‘treatment’ rather than manifestations of diversity in human neurological and social functioning. Within these models, the voices and perspectives of medical and health practitioners have been given much more weight than those with lived experience of disability. This has heavily influenced approaches to assessment and evaluation in health and disability services, in which the voices of those with disabilities are often overlooked.



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New theoretical discourse and political action over recent decades have urged a rethink of the validity of such approaches. This has created openings for more contemporary theoretical models and their informing of alternative approaches to service provision and assessment. International trends for individualised funding packages also reflect these social shifts, requiring service providers to be much more responsive to the expressed goals and wishes of clients, such as individuals experiencing disability. If we take the perspective that the function of therapy, and any other health or well-being intervention is to support the client/patient/consumer to live the life they wish to live, then it is vital that the endpoint considered is where clients are wanting to go in their lives. Thus, clients must be involved in setting that direction and charting their progress. Both of these endpoints have been underdeveloped, particularly in clients with intellectual disability to date, as we have explored in our research, but also undoubted by other groups who experience similar challenges in communication and self-advocacy. This results in both imperative and exciting opportunity for creative arts therapists to reflect on their own values and possible biases, and to explore how these may impact their approaches to therapeutic interaction and assessment. Interrogative reflection on questions such as: ‘Who’s goal is this?’, ‘Are we working towards outcomes meaningful to this person’s everyday life?’, ‘How accessible is my communication and assessment practice?’, ‘As a therapist, am I working for or with my client . . . or both?’, ‘How does my client feel about this work?’, begin to become central to good practice in creative arts therapies. JONES: I was especially interested in the way you position your research/ emerging practices in terms of working to ‘include the perspectives of participants, and provide meaningful information for participants’. What would you say you’ve taken from the research so far about the relationships between these two elements – perspectives ‘of’ and meaningful information ‘for’ client/participants? DUNPHY AND HENS: We had a number of reasons for working to include the perspectives ‘of clients’ in assessment, which we have depicted in the theory of change model below. This approach is frstly considered to provide meaningful information ‘for clients’, and to beneft them directly in increasing their ownership and agency in the therapeutic process and their understanding of its function. Simultaneously, we also expect that the therapist will be benefted, through being able to offer more effective service from having greater understanding of clients’ experiences and greater capacity to assess outcomes of therapy. We consider that taking this approach benefts all stakeholders, primarily clients, and their families and carers, but also therapists and other service providers. Ultimately it benefts the wider community with better use made of resources through more effective work.

314 Client–therapist relationship 

Perspectives of clients in assessment

Client’s enhanced understanding of outcomes of therapy

Client’s greater investment in the therapeutic process

Meaningful information for clients

Client’s enhanced understanding of outcomes of therapy

Client’s enhanced capacity to direct the focus of therapy

Meaningful information for therapists

Therapist’s improved capacity to understand clients’ experiences

Therapists’ improved responsiveness to clients’ needs

Therapist’s improved capacity to assess outcomes

Therapist’s improved capacity to plan to advance client outcomes

Client’s increased agency and control in daily life

Improved outcomes of therapy

Figure 17.1 Theory of Change model for inclusion of client voice in assessment

JONES:

The work included many different elements – quantitative scoring, qualitative note-taking, photos and videos – involving the perspectives of the therapist as well as that of the client, for example. How do you see the relationships between those different dimensions – in terms of how the different elements relate to each other – how they are valued, for example? DUNPHY AND HENS: MARA began frst as a tool to assist systematising and streamlining of assessment for therapists who are time-poor in their everyday professional practice. It was particularly developed for practitioners working in agencies where there was lack of investment in assessment to date or inadequate assessment processes. It was evident from the start that quantitative scoring needed to be accompanied by qualitative notes, at a minimum, in order that the assessment refected all the factors that might have contributed to those scores. This includes processes and activities within therapy sessions and issues that the client (or peers) might have brought to the sessions. Note-taking is also concordant with standard practice of therapists in writing case notes. Then we expanded the tool to include photo, video, audio recording and drawing options. These make more tangible the intangible and ephemeral process of participation in dance movement activities. These options also offer triangulation of therapists’ numerical scoring and notes. They afford the possibility of clients’ refection on their progress after the fact, in way that other types of data do not. They also provide information that is more accessible to lay-persons (clients, families/carers, non-DMT staff). Thus, different types of data are valuable to various stakeholders as detailed below: Management/programme funders: numerical scoring provides easily accessible data and qualitative data is also relevant as substantiation, for evidence of the contribution of the DMT programme.



 Efficacy 315 Clients and families/carers: photos and videos offer information that is easily understood by people without training in specialist jargon, and is especially accessible for clients themselves, particularly those with intellectual disability who have different literacy capacities. Research in creative arts therapies (CAT) professions: all forms of data offer triangulation possibilities and new insights, which are especially important with clients who have access only to non-verbal communication and therefore have limited capacity to use other assessment tools that rely on verbal processing.

This is very much an area of discovery and innovation. What do you consider as key strengths and challenges in developing the work to date and in taking it forward? DUNPHY AND HENS: A key opportunity for the development of this work currently is timing – these ideas are perfectly aligned with other contemporary social, political and cultural movements towards selfdetermination for all people. There is a growing impetus across a range of human service and health felds internationally to make client perspectives central to service planning and delivery. This includes major initiatives such as the National Disability Insurance Scheme in Australia, and other similar programmes internationally, that place the emphasis on the client’s experience. These advances are also very compatible with creative arts therapy models that support the advancement of client’s own agency and sense of self. They draw on the inherent capacity of creative arts to make communication more accessible, and provide a forum for clients to express and validate their experience of the world. There are also signifcant challenges. These include the newness of the ideas, in professional felds where assessment is already somewhat underdeveloped. There is also a potential barrier in the paradigm of evidence hierarchy, which has only recently begun to consider qualitative data as relevant evidence, with practitioners’ clinical experience and arts-based data often considered as being of lesser value. JONES: What are the main messages you would like to be heard from your research in terms of the development of good practice in the arts therapies? DUNPHY AND HENS: We strongly encourage arts therapists of all modalities to be actively seeking to improve their own practice and their potential contribution to clients’ lives by regularly assessing outcomes of their practice. Most effective is the use of standardised or validated assessment tools, provided those tools actually enable assessment of things that really matter in the modality. Currently much assessment in creative arts therapies, where it happens, uses tools from other professions (such as well-being indices from psychology or physiological tests from physiotherapy), thus potentially negating the fundamental creative processes underpinning our modalities. While there are few of such tools currently employed, and even fewer that include client perspectives, JONES:

316 Client–therapist relationship  our work is indicating that it is both possible and valuable. The use of standardised tools has an additional beneft in enabling the possibility of comparison of fndings within and across contexts. To those creative arts therapists who might be daunted by the prospect of systematic assessment or question its alignment with creative arts therapy ethos, we can say that our experiences of exploring assessment in DMT has revealed its capacity to increase refective practice and therefore quality in clinical practice. Using assessment tools need not be onerous, but provides an impetus to explicitly focus on and record how a client is progressing towards specifc goals. This leads to much more responsive and considered therapeutic goal setting and practice and can also be supportive of professional supervision processes. It is likely that this work is already done informally by many creative arts therapists, however formalising assessment processes can provide more avenues to share insights gleaned from assessment with stakeholders (importantly clients), which in turn can enrich and drive therapeutic processes. We are also learning that eliciting client views on their own experiences in therapy is not just a question of asking. It requires sound and sensitive therapeutic judgement; the upskilling of clients in self-reflection; tools and resources that create accessible avenues for self-reflection and careful consideration relating to timing and frequency. The research referenced in our recent chapter (Dunphy and Hens, 2018) and further research we are currently undertaking related to client self-assessment, reveal a necessity for further exploration of theoretical discourse and clinical practice in creative arts therapies to ensure clients are able to meaningfully steer their own therapeutic progress.

Example 2: Art therapy review of pictures As detailed earlier in this chapter, the methods used to evaluate the process and outcome of the arts therapies draw on a variety of forms. Researchers such as Curtis (2011) and Schaverien (1992, 1995) emphasise the centrality of image making and commentary or review in engaging with the evaluation of art therapy. Curtis draws on Housen, seeing ‘image-viewing’ as a ‘personal encounter’ connected to an individual’s concerns, locating the process of viewing and communicating about pictures within a relationship as open to reinterpretation, with viewers returning to images to ‘contemplate new meanings’ and to ‘synthesise ideas and perceptions’ (Housen, 2002: 127). Curtis summarises a tradition within art therapy literature that positions visual perception as an active process involving ‘the whole person who dynamically constructs meaning’ and that ‘art therapy literature has focused on the client’s personal interpretation and contextualization of art as the postmodernist alternative to measured analysis’ (2011: 9). Leclerc notes that ‘the image in art therapy cannot be read as a direct expression of the unconscious of the patient, but as a privileged indicator, a witness, of unconscious material, which sometimes takes a visual form to present



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itself’ and that ‘to contend that something is at once revealed and concealed means that the symbolic pictorial forms acts as an indicator for something unconscious. It reveals the presence of some unconscious material, or better still, it is itself revealed by the presence of something that is concealed, not fully exposed, explored, nor resolved’ (2006: 131). Referring to Schaverien, she goes on to offer a vignette illustrating the nuanced nature of meaning, relationship and association: During the session, I had vaguely noted that Genevieve is using more water than she usually does to mix the watercolors used in making her painting. The finished painting is now placed before our eyes. Silence prevails. As it is usually the case, Genevieve looks, or more, gazes at her image for quite a while, allowing the “life of the image,” as Schaverien (1992) puts it, to take over. Then, Genevieve speaks about the scenery and describes what appears to her as a landscape (her paintings are mostly abstract). However, something in her painting, not so much in what it represents, imposes itself on me, although I do not know exactly what. I note to myself that the image seems sort of clouded over; things appear to be vague, or to be vaguely disappearing or dissolving. I recall the thought I previously had about the amount of water used to create her painting. Tears? I then sense something like sadness, and am actually overtaken by a feeling of great sadness. “Like the view we get from a train on a rainy day,” I voiced after a while. Like a scene slowly unfolding from the window of departing train, the memory of a traumatic, painful experience comes back to Genevieve: her father, fearing his wife’s – my patient’s mother’s – mental illness, secretly took 4-year-old Genevieve and her 2-year-old brother from their home, by train, to his European country of origin. (Leclerc, 2006: 132) She reflects on this in the following manner: My patient had no conscious access to the depressive feelings related to the abrupt and yet unsymbolized experience of the separation with her mother. But she was able to induce that feeling in me through her pictorial representation or, more specifically, through the presentation effect her pictorial representation had on me. Because it is non-verbal, I believe the visual image in art therapy to be particularly apt to act not only as a locus for projections but also as a locus for the transmission and reception of infra-verbal and infra-representational forms of communication. (Leclerc, 2006: 133)

318 Client–therapist relationship  Drawing on the tradition of such approaches to positioning the role of the image and relationship within art therapy, Schaverien (1992, 1995) has documented the use of a retrospective review of pictures made by the client in evaluation. She makes the point that this is a fundamental difference from other forms of psychotherapy, and from the other arts therapies as ‘there is a series of lasting objects created by the patient’ (1992: 92). This offers data, but also particular opportunities in evaluating the process and development of the therapy. They are present in the moment of the review, but also ‘provide an instant recall of part of the session’ (1992: 93). The images are still alive – they reawaken processes seen from the perspective of the present – they recreate the therapy, providing a review of progress. In the review all pictures made, or pictures from a certain period, are assembled and looked at together and in sequence. This can be selfaffirming, to see the work created, but it can also ‘reveal connections and links which had been previously unconscious’ (Schaverien, 1995: 28).

Harry In reviewing paintings made over a nine-month period the client had made several pictures a day for a number of days each week. The pace had changed. In the review of pictures some of the following phenomena are noticed: •

• •

During part of the period the pace of production had slowed down. This is reflected on as being a period of regression, relating to ‘an early and regressed part of the transference’. Harry staying in the art room, close to the therapist. The style of execution changes when Harry begins to relate to others outside the one-to-one relationship with the therapist. Pictures become jokey – this is seen as a type of ‘adolescence’, when images are made to ‘impress’ peers rather than for the therapist.

Schaverien points out that the retrospective review of pictures has a role for the client in evaluating their process through the therapy, but also notes that the therapist’s experience of review is of use in understanding and evaluating the process which has occurred: ‘I was surprised to find how much I had previously missed; I thought I had seen these pictures but actually I had only seen a superficial layer. I now began to understand the web that they had woven me into . . . how these pictures with their powerful aesthetic quality had affected the countertransference . . . I had been absorbed into the inner world of the artist in the most subtle manner’ (1995: 29). She says that the images evoked what she calls a reawakening of the counter-transference. This develops into further reflection and



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understanding of the counter-transference and transference processes as manifested in the pictures, and her response to the retrospective review. A part of this involves insight into collective, as well as personal unconscious material within the pictures and their effects: ‘The patient was artist but also viewer, and each of these affected some aspect of the transference and countertransference’ (Schaverien, 1995: 31). The work, reviewed in sequence and in connection with the life history of the client, ‘offers unique insights into aspects of the person which may have been previously hidden or unconscious,’ (1992: 93) and ‘movement in the inner world of the patient’ (1992: 99). She parallels changes in the pictures with those taking place in the inner world of the artist/client. She suggests that the combination of the three: viewing made objects such as pictures in the context of sequence; attending to the maker’s meanings; and to the art therapist’s impressions, can offer insight into the ways the art therapy process effects a ‘change in state of the artist/patient’ (1992: 102).

The evaluation of the process is undertaken through the therapist and client both reviewing the work as a way of continuing to live with the images. As many art therapists have indicated, images produced in art therapy can offer different significances or meanings at different times. The retrospective review allows the images produced to act as a way of evaluating through the impact of re-encountering the physically present images. The presence of the artefact, Schaverien argues, offers a unique opportunity in evaluation as the reflection is not reliant on memory alone; it is also about how the consideration of the past process is encountered in the ‘here and now’ of the emotional impact of the image. Schaverien also illustrates the ways in which the process of seeing the images in sequence, combined with the evaluative perspective of the retrospective review, can be an effective way of enabling therapist and client to engage with the nature of change. She discusses a client, Ann, part of whose therapy had produced images associated with being beaten by her father when she was a young child: ‘Later when we reviewed the pictures, Ann was more separate from the feelings; they had become familiar and so less loaded with affect. This enabled a freer approach to the associations, and the therapist was able to make comments and interpretations. Links could now be made between these and other pictures and related to her current state’ (Schaverien, 1993: 123). One image of the father, for example, was painted in black; an image from a subsequent session was of a black spider. Schaverien says that in the retrospective Ann connected the two, and client and therapist made links and noticed how they affected them: ‘Because some time had elapsed, it was possible to play with possible links and make comments which would

320 Client–therapist relationship  have been impossible when the pictures were new . . . In the initial stages the pictures evoked very raw and painful feelings, and Ann was “identified” with them’ (1992: 123). The review allows for a reflective, evaluative perspective, but at the same time allows an emotional re-encountering with the image. These two combine to produce a unique evaluative process. In describing her approach Schaverien says that her influences are from two different fields – art history and psychoanalysis. The work of the art historian can include writing biographical material of artists making reference to art works and life history, and the artist may hold a retrospective exhibition of work in a gallery. The other tradition includes analysts who have written about patients who create art work: she refers to Jung (1959), Klein (1961) and Edinger (1990) as examples.

Example 3: Randomised control trial Recent years have seen the increase in the use of the randomised control trial (RCT) in relation to the arts therapies. Jeong et al. (2005) is an example of this approach. They undertook an RCT, situating their work within a context of clinical depression in Korea affecting about 8 per cent of adults and 14 per cent of 14–18-year-old adolescents each year (2005: 1712). Forty Korean middle school seniors (with a mean age of 16 years) volunteered to participate in this study and twenty were randomly assigned into either a dance movement group or a control group (n = 20). All ‘subjects’ completed a self-report inventory of emotional distress, the Symptom Check List-90-Revision (SCL-90-R) (Derogatis, 1977). In addition, plasma serotonin and dopamine concentrations were measured using high performance liquid chromatography by the Center of Pathology in the Green Cross Reference Laboratory. Commercial radioimmunoassay kits were used to determine plasma cortisol concentration involving collaboration with the Center of Clinical Pathology in Wonkwang University Hospital (2005: 1715). The trial reported that all subscale scores of psychological distress and global scores decreased signifcantly after the twelve weeks in the DMT group. Plasma serotonin concentration increased and dopamine concentration decreased in the DMT group. The report concludes that: These results showed that 12 weeks of DMT improved the negative psychological symptoms and modulated serotonin and dopamine concentrations in adolescent girls with mild depression. These data suggest that DMT has relaxation effects, stabilizes the sympathetic nervous system, and may be beneficial in improving the symptoms of mild depression. DMT may provide a simple, inexpensive, and practical therapy for depression in adolescents. (Jeong et al., 2005: 1719)



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The field is seeing an increase in this way of approaching efficacy and the kinds of insights it can offer. In 2013, for example, Lee and Thyer undertook a literature review of research aiming to give the field of music therapy a sense of the scope of such work. They looked in peer-reviewed journals in English between 2006 and 2012, identifying research where the methodology involved a randomised control trial that addressed the effects of music therapy (MT) alone or MT added to standard care (SC) on mental health among adults over the age of 18. They identified nine such studies. The conclusion was that: There is preliminary evidence to support the use of MT among adults with mental illnesses. All nine studies found initial positive effects of MT relative to no treatment or added to SC, and Erkkilä et al. (2011) found positive effects at 3-month follow-up. (Lee and Thyer, 2013: 601) One of these nine, a study by Chan et al. (2012), examined the effects of music on depression levels in older people in Singapore. This study was an RCT conducted in participants’ homes. Those involved either had music therapy lasting 30 minutes per week for eight weeks or had no treatment. Participants were recruited using snowball sampling of adults ages 55 and older who were diagnosed as being depressed. They were offered four different selections of music: Chinese, Malay, Indian and Western slow rhythmic music. Participants then chose one type of music to be played during the session. All clients completed the Geriatric Depression Scale weekly, beginning before and at the end of the study. The MT group ‘improved’ and was ‘statistically significantly more improved’ than the no-treatment control group at weeks 4, 6, 7 and 8 (the end of the study) (Chan et al. 2012: 776). This research exemplifies the following values in its enquiry: precision of attention; the effects of the arts therapy is constructed in a language that can communicate with, and across, other disciplines; it engages with replicability and with a quantitative approach to the complexities of an art form delivered within a clinical context. The benefits for the client are seen to be that such research can account for what we are discovering about arts therapy processes in ways that create dialogue with particular constructions of evidence-based medicine. The following example looks in more detail at another of these studies. At the Music Therapy Clinic for Research and Training, University of Jyväskylä, Finland, Erkkilä et al. (2011) constructed a randomised control trial to determine the efficacy of music therapy added to standard care compared with standard care only in the treatment of depression among working-age people. They situate clients’ experience of depression as causing problems such as a reduction in quality of life and loss of general functioning, noting that in Finland depression has become a common reason for inability to work and is prevalent in 5–6.5 per cent of the population. They argue that counselling or psychotherapy along with medication is the most common approach to treatment, but that verbal

322 Client–therapist relationship  processing may be difficult or insufficient for some individuals. The study focused on a single clinical method with a theory described by them as ‘improvisational, psychodynamic music therapy’ based on an interaction between free musical improvisation and discussion, and was theoretically anchored in a psychodynamic music therapy tradition. Music is seen by them as ‘an alternative expressive modality and a way to get in touch with emotions and develop relationships’ (2011: 137). The therapy was offered individually and in their research 79 adult participants ranging from 18 to 50 years of age, with a diagnosis of depression were randomised to receive individual music therapy plus standard care (20 bi-weekly sessions) or standard care only, and followed up at baseline, the end of the therapy, at three months and at six months after the intervention. The primary outcome measure of the study was the Montgomery–Åsberg Depression Rating Scale (MADRS), consisting of ten items. The role of the therapist was ‘to actively facilitate and support the client’s therapeutic process by using musical elements (i.e. rhythm, harmony, melody, dynamics, timbre) and interventions combined with reflective discussion’ (2011: 137). The therapists saw music therapy in the following way: Therapeutic process is based on the mutual construction of meaning of emerging thoughts, images, emotional content and expressive qualities that often originate from the musical experience and are then conceptualised and further processed in the verbal domain. That psychodynamic theory is common in active music therapy may have arisen from conceptual commonalities between them – for example, some of the typical concepts of psychodynamics, such as emotion, metaphor, association and image, are also core elements of musical experiences. . . . Musical expression in the sessions was based on a restricted selection of music instruments, including a mallet instrument (a digital mallet midi-controller), a percussion instrument (a digital midi-percussion), and an acoustic djembe drum. (Erkkilä et al., 2011: 137) The results showed that participants receiving music therapy plus standard care showed ‘greater improvement’ than those receiving standard care only in ‘depression symptoms, anxiety symptoms and general functioning’ at a three-month follow-up. The response rate was ‘significantly higher’ for the music therapy plus standard care group than for the standard care only group. Their summary draws attention to particular processes for many clients in the music therapy: •

Experiences during the non-verbal act of musical expression led to insights of certain aspects of their psychopathology as the experiences were further processed in the verbal domain.

 • • • • •

 Efficacy 323 Improvisational music therapy enabled working with and experiencing emotions associated with depression on a symbolic, non-verbal level. Musical, improvisational interplay between the client and the therapist also offers an open stage for transferences and creative imagery. Music therapy includes ‘active doing – i.e. playing music instruments’ – and so ‘inner pressure and feelings’ were often expressed. Playing was experienced as cathartic, and this may have led to corrective emotional experiences in further processing. The opportunity to be active was a meaningful dimension for dealing with issues associated with depression. (Erkkilä et al., 2011: 137) The overall conclusion of the randomised control trial was that: Individual music therapy combined with standard care is effective for depression among working-age people with depression. The results of this study . . . indicate that music therapy with its specific qualities is a valuable enhancement to established treatment practices. (Erkkilä et al., 2011: 137)

Example 4: Collaboration between disciplines Focus on Research Interview with Daniel Mateos-Moreno and Lidia Atencia-Doña The following concerns collaboration between two arts therapists, MateosMoreno and Atencia-Doña (2013), from different disciplines, working together with clinical psychologists, looking at dance/movement and music therapy with young adults diagnosed with severe autism. Mateos-Moreno and Atencia-Doña, a dance movement therapist and a music therapist, collaborating together, set two goals: firstly, to assess the effectiveness of their intervention based on the score the participants obtained from the Revised Clinical Scale for the Evaluation of Autistic Behaviour (ECA-R) after what they call ‘a series of dance/movement and music therapeutic procedures’ working with adult clients diagnosed with severe autism (2013: 465). The second goal was to ‘contrast the differences in effectiveness in concrete areas defined by subscales of the ECA-R’ (2013: 465). The enquiry was rooted in literature that connects the use of music therapy and dance movement theory to improvements ‘in communication disorders and to fostering adequate social behaviors’ though Mateos-Moreno and Atencia-Doña, as stated in their work, could not locate research that connected these benefits of the joint use of the modalities to therapy for individuals on the autistic spectrum.

324 Client–therapist relationship  The therapy took place over 36 one-hour sessions, twice weekly and involved eight clients with a control group of an equal size at the same centre. During the music and dance therapy eight measurements were taken (one every three weeks) from the work and from the control sample. These measurements were monitored by two independent psychologists. Sessions were led by both a music and a dance movement therapist, who were aided by three assistants and used what Mateos-Moreno and Atencia-Doña call a ‘plurisensory approach’ (2013: 466). They describe most sessions as involving eight activities. The ‘core’ of each session consisted of: ‘dance, instrumental practice, singing, and observation/mimicking of movement . . . patients sitting in a circle beat a tempo with percussive instruments imitatively and creatively with or without background music; . . . percussion and dancing whilst singing’ (2013: 466). The group imagined and simulated situations (e.g. a bird flying, a fish swimming); or emotions showed in pictures with gestures and movement connected to a lyric’s meaning or emotional content and movement ‘as a flamenco dancer’ (2013: 466). Throughout all the activities, therapists and aides intended to take their cues from participants in an attempt to reach a point where each individual could be ‘met at their developmental level’, and then ‘stimulated to move on to the next stage’ (2013: 467). The main data collection tool was the Revised Clinical Scale for the Evaluation of Autistic Behaviour (ECA-R) (Barthélémy and Lelord, 2003) used in order to assess ‘behavioral symptoms as a measure of music and dance movement therapy treatment efficacy’ on the clients. The two clinical psychologists used this scale to observe participants. Examples of the scale criteria included ‘imitation (no imitation of gestures or voice, lack of sharing emotion); contact (is eager to be alone, ignores people, poor social interaction)’ and ‘communication (does not make an effort to communicate using voice, lack of appropriate facial expressions and gestures, stereotyped vocal and voice utterances, echolalia)’ (2013: 467). Whilst noting that ‘similar to studies of this nature the reduced number of subjects (n-16) and the incidental sample selection lessen internal validity thus constituting indications for caution on generalizing results’ the study concluded that ‘the combined music therapy and dance movement therapy treatment was very successful: from the psychopathological standpoint offered by the ECA-R global output we found a high effect size’ (2013: 470). From the ECA-R ‘a significant difference’ was indicated for ‘the interaction disorder’ (Factor I) (2013: 470). Mateos-Moreno and Atencia-Doña conclude that: Musical activities (utilization of different kinds of music, singing, instrumental practice and rhythm) and body work through contact, through image and movements, provoked both physical and psychological well-being, inducing relaxed states in the subjects and an improvement in attention to activities. Therefore, this led to greater self-control of disorders in the emotional field; to better regulation of their impulses and capacities; to balance and lower alterations



 Efficacy 325 attained in different areas related to instinct (sleep, feeding and individual body activities); and to a better capacity for imitation, given that all learned activities were acquired initially by imitation and repetition, and the shaping of actions and games. This . . . helped subjects to understand and empathize with different emotions and to develop the self-acknowledgement of body schema and muscle tone. (Mateos-Moreno and Atencia-Doña, 2013: 471)

Key conceptual areas identified by them include ‘the distinctly peculiar channels of communication used by music and dance/movement, which are similar to emotions that excite the limbic brain and differ from regular channels governed by logic; their power for facilitating social interaction and integration; and the obvious multiple ludic possibilities of musical activities and dance, which may possess a motivational value for personal and collective expression’ (2013: 471). What would you say were the potentials and challenges of working together as a music therapist and dance movement therapist in relation to your approach to understanding effcacy? MATEOS-MORENO AND ATENCIA-DOñA: There is/was a very limited number of studies using a combination of both therapies. At the moment of undertaking our research, we could fnd no other peer-reviewed study matching a similar combination of therapies and oriented towards the autistic population. We were astonished to realise this fact given all the potential links that we could see between the two therapies. In terms of effcacy, we thought that the connections between both music therapy and dance/movement therapy could be stronger and the potential benefts much more interesting than that which was refected in the scientifc literature in reference to autism. Indeed, we had the feeling that other therapists may already have realised this fact even if the scientifc literature was so scarce in this area. Our thought was that combining music therapy and dance/movement therapy could yield in a sum of convergent potentials, based on, for example, the obvious connections between music and body-movement and their mutual transactions as arts. Therefore, we did not see effcacy as a challenge but as a very plausible output of such an intervention. Similarly, we saw no limitations or contradictions in using both music therapy and dance/movement therapy but, on the contrary, an addition of possibilities. The challenges in terms of effcacy as envisaged were only related to assuring suffcient evidence of validity that could make of our experimental intervention something plausible, replicable and thus useful for others. JONES: Did you feel that you had a mutual understanding of what effcacy means? Did your trainings prepare you in ways that enabled a mutual language, or were there differences? JONES:

326 Client–therapist relationship  This is an interesting question. The training of music/dance therapists can be controversial in many ways due to the many different origins of knowledge and competences that converge in each feld. Adding to this, the scientifc training required for both acting as a therapist and being able to read and apply research, can be experienced as extremely broad and diffcult to fully master. As a result, training in both the different scientifc grounds and the different praxis may differ a great deal between therapists. The differences become blatant if one compares the training of therapists from different countries, or even among institutions in the same country. Not to mention the many ways to achieve an accreditation (through Bachelors, Masters, PhD, or other graduate programmes). Nevertheless, we perceive a mutual understanding of effcacy by all therapists, starting at frst-hand from the therapists’ experience and their ability to develop a sensitivity to progress through pure observation. In our view, the ontological and epistemological debates which have occupied scientists and science theorists in terms of measuring effcacy – e.g. the controversy between positivistic approaches (i.e. pure quantitative studies) or interpretivist (i.e. pure qualitative studies) – are not of a such great value in relation to the very praxis of an arts therapist. The essential need is for the therapist to develop a ‘researching eye’ and suffcient knowledge of different research techniques. Beyond the praxis, at the pure research level, the consequences of such a debate in reference to measuring effcacy can be also controversial in the feld. On one hand, there could be no single quantitative study without a previous operational defnition of the variables to measure. On the other hand, there could neither exist a qualitative art-therapy research where, for example, the perceived duration or repetition of behaviours, stimuli and interventions were of no means for those interviewed. In our very particular case, we felt that the way of working with our chosen data collection tool as completed by two external clinicians was in absolute concordance with what we felt it appropriate to work with during the length of the therapy. The Revised Clinical Scale for the Evaluation of Autistic Behaviour (ECA-R) proved to be a very a useful tool, perhaps because (as stated by its authors) the scale is very easy to complete on a regular basis and reveals appropriate data from clients for longitudinal and multi-centre studies. Moreover, we felt that we took an extensive sample supporting our measures of efficacy. This was constituted of eight measures, one every three weeks, by two experienced clinician psychologists who first independently rated our participants and thereafter hold meetings together to discuss possible disagreements in order to provide an agreed score. Beside the qualitative measures, our study made use of quantitative analyses that involved a robust statistical approach. This approach is by definition less sensitive but more specific, contributing to minimising possible errors stemming from the qualitative part of the study. In our attempt

MATEOS-MORENO AND ATENCIA-DOñA:



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to provide evidences, we estimated effect size by three different statistical methods (i.e. Partial Square Eta, Partial Square Omega and Cohen’s d) which were fully coincident indicating a significant progression of patients. JONES: What was the relationship between your design of the dance movement therapy–music therapy activities within the sessions and the chosen method of data collection? MATEOS-MORENO AND ATENCIA-DOñA: Selections of measuring instrument and analytical procedures were undertaken subsequent to the design of our approach to using music and dance movement therapy together. In other words, we were not worried at all on how the experiment was going to be assessed during the process of creating the activities that we would pursue with patients. On a conscious level there was no effect. It nonetheless is diffcult to acknowledge if there was some infuence present at an unconscious level. However, if we rethink on the reasons that led us to choose the ECA-R afterwards, we cannot see any single matter connected with the content of the intervention itself. On the contrary, our reasons were mainly based in the adaptability of the instrument to a longitudinal study with individuals with a diagnosis of autism, the clearness and easiness of its utilisation, and the proved good psychometric qualities of the ECA-R. JONES: Do you think the combination of the two modalities had particular value in terms of the effcacy of the work for your clients? MATEOS-MORENO AND ATENCIA-DOñA: So as to differentiate the effects of the two modalities of therapy separately and in relation to our intervention, one would need to replicate our experiment with MT interventions and DMT interventions. We were not so much interested in differentiating the potentials of the different activities. Conversely, we were interested in the power of the intervention as resulting of their combination. Nevertheless, our intuition, as stated in the discussion of the published article, was that the combination of both therapies may involve an increased potential. As a gestaltist would say, it is very possible that the resulting potency was not exactly equivalent to the isolated sum of the separate music therapy and dance/movement therapy activities. In any case, our hypothesis is that it was the peculiar blending of music therapy and dance/movement therapy activities and its different channel of communications, both connecting to emotions, exciting the limbic brain and leading to greater capacities to modulate self-adaptive behaviours. To clarify, multiple channels of stimulation that in many ways converge, as happens with the emotional and social opportunities created by both music therapy and dance/movement therapy activities, may well justify an increased potential for clients through their combination. It would be interesting, though, to undertake further studies that can prove if this hypothesis is true. JONES: In retrospect what do you think were the main strengths and limitations of the approach you used?

328 Client–therapist relationship  Any approach has strengths and limitations. Those must be examined in relation not only to the scientifc methods involved but also to the content (what is researched), the context (what other similar studies exist in the feld), and the ethics that act as a ground for the decision-making process. For example, the selection of patients to each group was incidental in our study. This acted as a limitation, since absolute randomisation constitutes an obvious desire in science. However, the selection was not done by the researchers or under any kind of prescriptions in relation to the study, but independently by the staff of the specialised care centre where all participants were being continuously monitored. The ethics behind the selection was to avoid disrupting pre-existing settings. In addition, there were benefts with this non-randomised selection considering our particular population in terms of minimisation of the reactive effects of the experimental procedures employed and providing evidence of ecological validity. This last together with the fact that both experimental and control groups were made up of patients with approximately the same age (n = 16, M = 25.62 in group 1 and M = 25 in group 2), with similarly no experience of any instruction in music or dance, and all being patients from the same care centre, can help much in avoiding confusing variables. One could argue that the sample could be larger, and that is a possibility that we certainly propose for future studies. Notwithstanding, the aforementioned high efficacy of the intervention detected by three concurrent calculations of effect-size counteracts the very unlikely possibility that our results were really compromised by our sample-size. This is why we think that our study can be considered both as evidence of efficacy per se and as a solid foundation for continuing studying the combination of MT and DMT in future research. Those studies could be randomised in ways that maintain our same ethical concerns through, for example, being replicated in different care centres, varying parameters (time, activities, number of measures, etc.), and making use of different practitioners or different evaluation procedures. In any case, based in our research, those studies are required to be done in the framework of long-term trials as we found that statistically significant differences in the evolution of patients were mostly present in every two consecutive measures (which is, every six weeks of treatment).

MATEOS-MORENO AND ATENCIA-DOñA:

A ‘researching eye’? The examples illuminate aspects of the complexity of this area: the different kinds of needs and demands present in all situations concerning effcacy. These include those of the client, the therapist and the organisation funding or governing policy in relation to the provision of therapy. Arts therapists are fnding ways of working that relate both to a client’s situation and to the demands of institutions or service providers’ policies and understandings. Many arts therapists within this chapter have pointed out that it is necessary



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to fnd a systematic way to understand effcacy, one that looks towards ascertaining how effects can be acknowledged, or reproduced and communicated to those outside the therapy session. In this work, though, it is important to bear in mind the challenges that have been raised. There can be the temptation within some settings, and within some client–therapist relationships, to need to feel that there can be unquestionable certainty about a particular approach to evaluating effcacy. As this chapter has shown, there are important doubts, questions and ambiguities that are necessarily a part of the therapeutic endeavour. Perhaps the most useful thing about such voices, is that they should be with all those looking at effcacy, to remind us of the subtlety and complexity of relationships involving therapy and the arts. Clarkson advocates that different kinds of relationships are used for different clients in understanding the nature and effect of therapy (2002b). This tends to echo the ways of working with efficacy reviewed in this chapter and elsewhere in the book. Two of the interviewees in this section identified the need for arts therapists to develop ‘a “researching eye” and sufficient knowledge of different research techniques’ (Mateos-Moreno and AtenciaDoña). This chapter has shown a number of innovatory visions concerning efficacy, as arts therapists develop this ‘researching eye’. We have sampled the broad and energetic creations of arts therapists’ new thinking and practice, their creation of dialogue with other disciplines and involving clients in a wide diversity of experiences of engaging with the efficacy of their therapy. Therapist and client have found themselves engaged with an app, MARA, viewing photos and short videos of themselves taken during sessions; reviewing images of fathers as black spiders; listening to different selections of Chinese, Malay, Indian and Western music; playing digital mallets and acoustic djembe drums, creating body work through contact, image and movement and measuring plasma serotonin and dopamine concentrations using high performance liquid chromatography. Therapists have accompanied this diversity of engagement with a range of concepts and practices to support their work: drawing on theories of transference and countertransference; the ‘motivational value of personal and collective expression’; using concepts and standardised tools developed within the discipline such as the ‘Outcomes Framework for Dance Movement Therapy’ and utilising frameworks from other disciplines such as the Montgomery–Åsberg Depression Rating Scale (MADRS) or the Revised Clinical Scale for the Evaluation of Autistic Behaviour (ECA-R). As the examples in this chapter have illuminated, the ways the arts therapies are responding to the questions of efficacy are varied, innovative and creative.

Conclusion Much recent enquiry has engaged with ‘effcacy’ in the arts therapies and this area is vital to the future. The need is to continue to develop the diversity of ways of understanding the processes and outcomes of the arts therapies; to recognise the complexities of the arts and science connection in innovating processes and languages; and to identify how best to communicate our

330 Client–therapist relationship  fndings. The need is to continue to create shoes that ft in this area, rather than to try to ft into others’ existing shoes – this might damage the feet, and hinder movement! It is also vital to continue to create dialogue – the need to acknowledge and represent the differences of the arts therapies in relation to other models or approaches to change and effcacy. It is also vital to keep the voice and presence of the artist part of the arts therapist and client in organisations or settings that can often be ill at ease with the ambiguity, idiosyncrasy and mutability of the arts. Some, such as Bunt (1990), have echoed this, and argued for the kinds of initiatives and dialogues that this chapter has illustrated. Though the danger is that the complexities of artistic process can be reduced to ‘almost naïve proportions’ in quantifying results, it is possible to bring different strategies and approaches to fnd ways of converging to increase ‘our understanding of the whole picture’ (1990: 6). Bunt has said that research in the arts therapies offers the opportunity to bring together areas often kept apart in the Cartesian mind/body split ‘that still permeates many of the debates within healthcare and our growing research tradition’ (Bunt, 1990: 2): the irrational, feeling-centred and bodily versus the clarity of mind and drive for rational order, adding that ‘it is surely a sign of good health to blend objective knowledge with subjective feeling’ (Bunt, 1990: 4). Warth et al. (2015) talk about the importance of interdisciplinarity: that collaborations between music therapists, physicians, psychologists, statisticians and nurses may lead to a synergic concentration of expertise and help overcome advanced methodological challenges (2015: 365). They echo some of the themes in this chapter: ‘music therapy researchers have expressed concerns about the standardization of their interventions, pre-defned guidelines regarding therapy procedures are generally considered a prerequisite for treatment fdelity and reproducibility of treatment effects’ (2015: 355). However, they argue for a mediated position where music therapy researchers have to ‘balance between accounting for individuality of patients on the one hand and producing standardized and replicable interventions on the other’ (2015: 355). Perhaps we can expand Mateos-Moreno and Atencia-Doña’s notion of the ‘researching eye’ to create a developing goal for engaging with effcacy in the arts therapies: of a new, unifed ‘whole’ of the researching mind, body and imagination? The examples within this chapter illustrate the ways this journey is already being developed by arts therapists, as they assemble diverse elements to create a ‘whole’. They bring together the rigour of understanding how arts processes involving the sensual, creative individual encounter through image making or drumming interconnect with ways of analysing connected to the ‘clarity of order’ spoken of by Bunt.

eighteen

Concluding remarks

In her work, Human Minds: An Exploration (1992), Donaldson argues that Western cultures and attitudes have narrowed how we enable the human mind and the world to interact. She analyses other ways of being and relating that she sees as broader and richer, that ‘expand the repertoire’ of relationship (1992: 190). As an example, she draws extensively on the experiences and writings of Milner, described by Case and Dalley as ‘a fgurehead and a person to emulate for many art therapists’ (Case and Dalley, 1992: 81). It may seem strange to cite a description of viewing seagulls, frst published in the 1930s by Milner (under the pseudonym Joanna Field), at the close of The Arts Therapies, but I think it’s important to do so and to return to the image of fying from page 306: One day I was idly watching some gulls as they soared high overhead. I was not interested, for I recognised them as ‘just gulls’ and vaguely watched first one then another. Then all at once something seemed to have opened. My idle boredom with the familiar became a deep-breathing peace and delight, and my whole attention was gripped by the pattern and rhythm of their flight, their slow sailing which had become a quiet dance. (Milner, 1986: 71) Donaldson amplifies her concerns about aspects of many contemporary modes of relating by drawing on Milner’s distinction between what she called ‘narrow focus attention’, and a different way of being. Narrow focus attention selects what serves its immediate interests and ignores the rest. Milner likens it to a questing beast keeping its nose close to the trail. What she calls wide attention becomes possible only when these ‘questing purposes’ cease to be in control, ‘to attend to something and yet want nothing from it, these seemed to be the essentials of the second way of perceiving’ (1986: 186). Donaldson comments on Milner’s experience of herself and the gulls in the following way: ‘In brief, what happened was that, quite unexpectedly, she saw the birds in a new way that changed idle boredom into “deep-breathing peace and delight”’ (Donaldson, 1992: 239). Donaldson goes on to argue for the importance of the intuitive, for the importance 331

332 Concluding remarks   of feeling as a way of perceiving. The narrowness of expecting what was to be perceived stopped the actual seeing of what was there: ‘vivid pictures of what might happen shut me off from perceiving what actually did happen’ (Milner, 1986: 186). Donaldson goes on to stress the importance of acknowledging this way of relating, the ‘reality of feeling’ and experiences that transcend the personal, ‘these are facts of the greatest importance for human lives and for the possible development of human societies’ (Donaldson, 1992: 244). In the pressure for precise, highly selective ways of looking, and the drawing of conclusions based on narrow, focused notions of evidence and concern, such ‘whole attention’ (Milner, 1986: 171) in healthcare is an important one to bear in mind. As the arts therapies develop further, and as clients and therapists work together to discover more about them, the nature and value of change in the arts therapies will become ever more established and articulate. This will not, and should not, happen by the arts therapies using one approach or framework: rather, as Grainger says, ‘we need to have several different languages at our command’ (1999: 143). This book has given a picture of some of the different languages that the arts therapies are using to discover and communicate their many potentials.

It can be a deeply moving process to see people fight free and emerge. . . . both client and therapist are changed, through the process and the relationship. (Nowell Hall, 1987: 157)

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Author index

Aalbers, S. 301 Abdullahi, A. 303 Abra Gaga, D. 303 Adeyinka, N. 48 Aiello, R. 173 Albers, J. 83, 84, 86, 87 Aldridge, D. 38, 147 Aluede, C. 4–5, 40, 73, 75, 76, 77–82, 87, 88 Alrazain, B. 121–122 Alvin, J. 90, 95, 127, 153 Amir, D. 141 Andersen-Warren, M. 50, 197, 201 Artaud, A. 84 Atencia-Doña, L. 240, 323–330 Axline, V. 200, 201, 203, 205–206 Banks, L. 234–235 Barber, V. 259–260 Barham, M. 98 Bateson, G. 171, 210 Baudrillard, J. 300 Blatner, A 196, 229 Bogen, C. 73, 74–75 Bondi, L. 242 Boulez, P. 169 Bourgeois, L. 167–169 Bourne, L. 108, 109, 207 Bowlby, J. 197 Breton, A. 158, 165–166 Bromberg, E. 37 Bunt, L. 3, 42, 44, 45, 46, 94, 95, 96, 152

Butler, J. 52 Byrne, P. 87, 129, 297 Cage, J. 83, 84, 85, 86, 169 Callaghan, K. 121, 140 Cameron, D. 31–33, 85 Campbell, J. 259–260, 303 Case, C. 13, 135, 136, 173, 180–181, 193, 197, 200, 241, 283, 331 Casson, J. 47–48, 54, 74, 137 Cattanach, A. 214, 229, 249, 258, 259 Chan, M. 321 Choe, N. 137–138 Clarkson, P. 13, 26 Cosgriff, V. 43 Couroucli-Robertson, K. 214 Courtney, R. 177, 196, 223 Cox, M. 13 Croall, J. 66, 74 Dalley, T. 13, 135, 136, 173, 180–181, 193, 197, 200, 283, 331 Danev, D. 62 Darnley-Smith, R. 152, 167 Dawes, S. 45–45 De Sade, D. 89 Dewey, T. 83 Diaghilev, S. 5 Dieterich-Hartwell, R. 282–283, 312 Dokter, D. 51–52, 56, 178, 283 Donaldson, M. 331–332

361

362 Author index Dosamantes-Beaudry, I. 250–255, 267, 268 Douglas, M. 112, 113, 114, 115 Dubowski, J. 220 Dunphy, K. 309–316 Duggan, M. 201 Edwards, D. 301–302 Edwards, J. 39, 40 Edwards, M. 96, 97, 98, 108, 109 Ekstrand, J. 108, 109, 112, 115, 207 Else. B. 297–298 Erkkilä, J. 321–323 Ernst, M. 165 Evans, J. 220 Feder, B. 299, 305 Feder, E. 299, 305 Ferrara, N. 258–259 Fleshman, B. 89–90 Fontana, D. 49–50, 160, 304–306 Foucault, M. 89, 90, 97, 112, 114 Freud, A. 200 Freud, S. 161–166, 168–170, 173, 178–179, 184, 189, 204, 217, 244, 254 Fryrear, J. 89–90 Gardner, H. 292–293 Garvey, C. 203, 204, 209 Ghiselin, B. 175 Gilroy, A. 95, 110, 111, 112, 273–274, 301 Gobey, F. 232–233 Grainger, R. 50, 170, 171–172, 179, 197, 201–202, 230–231, 301, 332 Gropius, W. 83 Gruhn, N. 90, 91–93, 95, 118, 153 Gwinner, K. 22–23, 82, 83, 145 Haack, B. 133–136 Halley, P. 112, 114 Hämäläinen 122–124 Hanna, J. 121–122 Harris, D. 241, 277–283 Harris, J. 83, 85, 184, 204, 213–214 Harrison, C. 112, 165–166 Haythorne, D. 47 Helman, C. 243–244 Hens, T. 309–316 Hickling, F. 89

Hill, A. 95 Hin, A. 104–106 Hitchcock, A. 165 Hitchcock, D. 172–173 Ho, R. 261–268 Hogan, S. 245 Holmwood, C. 49 Hougham, R. 50, 160, 169, 184 Hoskyns, S. Ikuko, S. 43 Ilse, O. 62 Jaaniste. J. 295, 305 James, J. 145–146, 174–175 Jarry, A. 5, 6 Jennings, S. 9, 13, 48, 94, 95, 157, 195, 223–234, 228 Jeong, Y. 320 Jones, P. 20, 49, 50, 74, 75, 89, 90, 91, 94, 95, 175, 177, 195, 205, 207, 208, 210, 212, 215, 217, 223, 225, 228, 234, 243, 290, 294–295, 297, 302. 305 Judges, A. 90, 91–92, 93, 95 Jung, C. 12, 37, 83, 87, 89, 116, 130–131, 149, 160, 163–164, 171–172, 181–182, 244, 254, 320 Kalmanowitz, D. 261–268 Karkou, V. 26, 27, 28, 56, 160, 302 Klein, M. 128, 133–4, 160, 167–9, 200, 217, 239, 244, 245, 254, 320 Koch, S. 282–283, 312 Kristeva, J. 226 Kuhn, T. 9, 236 Laban, R. 85, 312 Lacan, J. 158–159, 166, 254 Lai, K.K. 104–106 Laing, R. 244 Landy, R. 53–54, 72, 75, 117, 177, 178, 221–222, 299 Langer, S. 222–223 Lanham, R. 37–38, 116, 127–128 Lauw, E. 240 Lawes, M. 141–144 Leclerc, J. 160, 188–191, 192, 316–317 Lee, C. 95, 110, 111, 112 Levens, M. 218 Li, T. 127

Author index 363 Lindkvist, M. 50 Loizos, C. 208, 210 Lyotard, J. 5 Mackenzie, N. 224–225 Maclagan, D. 185 Mahtani, A. 192–3, 217 Malchiodi, C. 22, 30, 195, 203 Maslow, I. 306 Masson, A. 158–159, 164, 166 Mateos-Moreno, D. 240, 323–330 Mauro, M. 303 McAlister, M. 10–11, 210–211 McClelland, S. 179–180, 301 McDougall, J. 175 McFee, J. 125, 132 McNiff, S. 6, 13, 62, 72, 114, 115, 183, 235, 298, 307 Meekums, B. 55, 56 Messaien, O. 169 Milioni, D. 183, 268, 299 Milner, M. 331–332 Mundy, J. 165–166 Murphy, J. 36, 204, 227–228 Nadirshaw, Z. 283 Naumburg, M. 30 Nippoda, Y. 244 Nordoff, P. 39, 90, 95, 148, 152, 255–257, 285 Oatley, K. 178–179 Odell, H. 186 Ogunyemi, F. 195, 198–199 Okazaki-Sakaue, K. 25, 26, 43, 90–91 Orr, A. 246 Parry, G. 292, 301 Pavlicevic, M. 41–42, 79, 111, 116, 125–126, 147–148, 150, 186–187, 244, 285–290, 305 Payne, H. 23–24, 42, 55, 58, 298 Pendzik, S. 49, 241 Perls, F. 83, 84, 87, 249 Petzold, H. 62 Pitruzzella, S. 67, 68, 72 Piaf, E. 86 Piaget, J. 202, 204, 209, 210 Priestley, M. 39, 184 Prinzhorn, H. 7, 97

Ragpot, L. 195, 198–199 Rauschenberg, R. 83–86 Read Johnson, D. 70, 87, 202, 205, 207, 228, 249, 253, 254, 259 Redhouse, R. 218–219 Reil, J. 74 Robbins, A. 39, 90, 95, 148, 152, 285 Rosenbaum, M. 198 Sajnani, N. 24–5, 49, 54, 111, 243 Schaverien, J. 28, 98, 99, 225, 231, 301, 316–320 Schawinsky, A. 85 Schechner, R. 209 Senior, P. 66, 74 Seymour, A.47, 54 Shapero, B. 175, 249 Sharma, U. 112, 227, 239, 242–245 Silverman, M, 133–136 Silverman, Y. 144 Singer, D. 197–198 Skaife, S. 33–35, 111, 128, 147, 229, 254, 272, 274, 276 Skewes, K. 42, 45, 232 Slade, P. 74, 275 Smith, M. 20, 109, 152 Smitskamp, H. 206, 208, 235, 237 Snow, S. 50, 177, 196, 312 Stanton-Jones, K. 55, 57 Steiner, M. 57–58 Stern, D. 187, 250 Stevens, R. 254 Stockhausen, K. 136 Taylor, S. 6, 297 Theilgaard, A. 217 Thomas, K. 162–163, 170, 174–175 Tyler, H. 169 Valente, L. 49–50, 160, 304–306 Viola, B. 60 Vygotsky, L. 199 Wadeson, H. 22, 229–230 Wald, J. 30, 111 Walker, R. 73, 186 Waller, D. 30, 107 Warner, M. 115, 146–147, 149, 168 Warwick, A. 61–62

364 Author index Watson-Gegeo, K. 207 Wheeler, B. 298 Wigram, T. 42, 63–65 Wilshire, B. 216 Wing, A. 104–106 Winnicott, D. 160, 163, 189, 197, 200, 201, 205, 214, 228 Wiser, S. 177–178, 180, 295

Wood, C. 31, 112, 130, 144, 154–155, 276, 305 Wood, M. 142, 175 Yiu, F. 104–106 Young, M. 227 Zollar, J. 56

Subject index

accreditation 18, 326 active imagination 149, 181 active witness 11, 174, 180, 189, 203, 219, 222, 226, 230–235, 251, 253, 263, 282, 316 addiction 24 aesthetics 59, 69, 111, 136 Africa 3, 4–5, 14, 25, 56, 60, 72, 77–82, 102, 103, 107, 132, 195, 197, 199–200, 277–283 L’Age d’or 265 AIDS 69, 199 aims 18, 22, 30–38, 42–46, 50–54, 57–59, 65, 69, 87, 106, 129, 131, 133, 196, 247–269, 270–291 American Art Therapy Association (AATA) 24, 28, 37, 99 American Dance Therapy Association (ADTA) 20, 56 American Music Therapy Association (AMTA) 40, 73 anthropology 68 archetypes 163–164 Argentina 197, 207 Ariadne’s thread 158–159 art brut 7 art psychotherapy 22, 29, 30, 188–191, 248, 253–255 art studio 30, 261–266, 271; see also arts space, play space art therapy 22, 24, 26, 60, 62, 64, 67–68, 74, 76, 83, 95, 96–99, 102–104, 110, 111, 117–118, 120, 122, 124, 127–130, 135–136, 137–139, 141–142, 186–189,

258–264, 314–318; defnitions 28–30, 67–69, 96–99, 100–103; history 28–30, 71–76, 83–85, 89–91, 96–103, 269, 294 Art Therapy Association of Colorado (ATAC) 28 artist role 120–123, 141–156, 158–161, 164–170, 173–174, 178–179, 187, 188, 192, 222–223, 226–227, 229–230, 242–244, 247–248, 270–277, 284–285, 290–291, 297–300, 318–320, 329–330 artistic projection 216–219, 221; see also projection artistic skill 23–4, 42, 78, 100, 111, 128, 129, 136, 138, 139, 150, 171–172, 242–243, 271, 274, 276, 287 arts and science 78, 80 108–118; see also science arts in health 4, 65–67, 75 arts space 117, 126, 129–132, 136, 261–266, 271; see also play space Asia 5, 6, 20, 24, 25, 42, 43, 45, 60, 67, 75, 81, 90–91, 104–106, 107, 107, 195, 246, 295, 321, 329 assessment 49, 51, 55, 61, 63, 64, 82, 98, 212, 256, 293, 303, 309–316; see also effcacy, evaluation, evidence, meaning Association for Dance Movement Therapy (UK) (ADMT) 57 autistic spectrum 64, 204, 220, 323–329

365

366 Subject index behavioural therapy 120, 248, 250, 255, 256, 262, 275, 276, 294, 299, 309 Bellevue Hospital 89 Bharata 59 Bio-Music Association 91 Black Mountain College 5, 6, 77, 83–87, 106 body 22, 25, 30, 52, 53, 55, 56, 58, 61, 75, 80, 81, 84, 112, 121, 122, 147, 151, 153–155, 175, 177, 183, 194, 213, 223–226, 228, 243, 251, 257, 263, 266, 272–273, 278–279, 284, 306, 307, 324–325, 329, 330 Brazil 6, 20, 28, 41, 77, 89, 91, 107, 109 British Association of Art Therapists (BSMT) 29, 30, 37, 38, 99 British Association of Dramatherapists (BADth) 48 British Medical Association 74 British Society for Music Therapy (BSMT) 40 Bulgaria 30 cancer 218, 306 care 2, 13, 14, 15, 19, 24, 31, 38, 52, 65, 68, 72, 73, 74, 75, 82, 83, 96, 97, 98, 101, 102, 103, 109–15, 118, 124, 129, 176, 244, 245, 285, 286, 287, 289, 292, 293, 301, 302, 310, 312, 313, 314, 321 case study approach 133, 137–139, 248–252, 253–254, 255–260, 260–263, 293, 300, 301–302, 308, 317–320 les Champs Magnetique 158 Charenton Asylum 89 Un Chien Andelou 146 children 6, 8, 25, 30, 36.37, 40, 43, 47, 53–60, 62, 76, 89, 90, 94, 95, 102, 105, 110, 122, 128–135, 148, 152, 154, 194–214, 220, 224, 226–228, 232, 241, 256, 277, 284, 286, 288, 294–296, 303; see also play China 5, 75, 81, 104–106, 107 class 244, 246, 303 client 10–11, 12–13, 14–15, 18, 22, 30–31, 40–42, 47–54, 56–7, 59–62, 65, 96, 99–101, 110, 121, 124–137, 137–141, 247–269, 270–291; contexts and social

justice 25–26, 30, 41–42, 61, 110, 112, 113–114, 121–122, 128/; and meaning making 42, 44, 53–54, 56, 117, 146–158; range in the arts therapies 24, 30–32, 37–38, 44, 90–1, 105–106, 109, 131–133 client – therapist relationship 11, 12–13, 14–15, 18, 28–30, 31, 37, 49, 58, 135–136, 141–146, 247–269, 270–291; see also therapeutic relationship; triangular relationship client voice/accounts of the arts therapies 22–23, 33, 34, 45–46, 47–48, 114, 136–137, 142–143, 145, 288–289, 295, 302, 305, 309–316, 330 Clinical Music Therapy Association 91 cognition 37, 147, 177–178, 186, 212 cognitive behavioural therapy 120, 262, 275, 294, 299 communication 5, 8, 9, 28–31, 37, 39–44, 50, 51, 55–58, 63, 64, 78, 86, 100, 121, 123, 126, 130, 131, 152, 153, 155, 171–176, 183–187, 189–190, 192, 196, 199, 205, 209–213, 219, 223–226, 228, 242, 255–259, 300, 302, 304, 310, 313, 315, 323–327; see also non-verbal community 4, 19, 26, 28, 39, 65, 66, 67, 74, 78, 84, 85, 89, 102, 106, 113, 114, 121, 132, 243, 245, 264, 277, 279, 281, 285, 288–290, 301, 303, 313 computers 199; see also virtual art therapy studio Conference of the Society of Music Therapy and Remedial Music 7 confict 28, 29, 31, 32, 37, 42, 74, 85, 140 core processes 213–236 counselling 11, 21, 44, 254, 267, 293, 302, 321; see also transcultural counselling countertransference 318–319, 329; see also transference creativity 5, 8, 22, 31, 33, 48–51, 62, 68, 69, 74, 75, 116, 117, 120, 124, 125, 130, 132, 136, 152, 157, 161, 168, 181–183, 192, 195–196, 200, 202, 207, 215, 219,

Subject index 367 220, 229, 230, 237, 275, 291, 298, 300, 306 Croatia 62 culture 4, 5, 24–26, 59, 60–61, 70, 72, 79, 108, 119, 130, 137–141, 155, 157, 162, 164, 165, 168, 181, 186, 195, 197, 230, 242–246, 259–260, 264–266, 270–272, 275, 277–294, 297, 302–303, 309, 331; ‘experienced’ culture 8–9; and health 41, 56, 66, 73–74, 86, 109, 112, 115, 120–121; and identity 14, 60, 68, 114, 123; and power 24, 72; see also intercultural, transcultural counselling Czechoslovakia 165 dance movement therapy 178, 220, 274, 250–253, 277–285; defnition 55, 57–58, 121; associations 20, 56–8, 96, 104; history 71–76 dance movement psychotherapy 55 defence mechanisms 163, 173, 177, 189, 192, 241, 299 depression 29, 42, 56, 58, 80, 109, 141, 142, 168, 301, 321–323, 329 developmental approach 12, 37, 40, 51–52, 55, 155, 195–196, 200–202, 204, 212–213, 232–233, 242, 248–249, 255–260, 267, 268, 274, 289, 292–293, 324 diagnosis 92, 96, 98, 110, 218, 234, 296, 303, 322, 327 disability 95, 176, 310, 313; intellectual disability 285–290, 315; social model 285–6, 287, 288, 289, 312; United Nations Convention on the Rights of Persons with Disabilities 310 disenfranchisement 243, 275 dramatherapy 160, 178, 195, 201, 211, 217, 218–220, 224, 225, 230, 294–295, 299, 304; defnitions 47–47; associations 48–51; history 71–76 dreams 6, 9, 73, 87, 147, 163–166, 173, 174, 182 drugs 231, 234; treatment 96 eating disorders 51–52, 218 Ecarte 67

ecosystemic 309–316 education 8, 9, 10, 18–19, 22, 24–27, 31, 33, 60, 67, 74–76, 84, 86, 91, 92, 94, 95, 103, 110, 112, 127, 128, 131, 196, 198, 199, 283, 302, 303, 310; and ‘special schools’ 40, 58, 75, 90, 91, 94; and theatre in education 66 effcacy 14, 99, 110, 136, 180, 283, 285, 292–328 embodiment 150, 156, 175, 178, 216, 223–226, 252–253; see also body emotional encounter 177–180 empiricism 147 empowerment 48, 54, 56, 252–253, 275, 282, 288, 289, 295, 305–307, 310 see also client accounts/voice, ecosystemic Erotika Review 164 ethics 67, 101, 190, 328 Eurocentric 25 Europe 5, 25, 29, 30, 37, 38, 42, 50–51, 62, 67, 81, 83, 97, 99, 165, 195, 294 evaluation 109, 110, 295, 296, 300, 303, 309–316, 316–320, 320–323, 323–328; see also client accounts/ voice; effcacy evidence 160, 178, 196, 198, 292–328 evidence based medicine 293, 321 expressive arts therapy 20, 62–63, 104 family 10, 14, 25, 31, 37, 44, 53, 84, 106, 121, 144, 198, 209, 210, 218, 225, 232–233, 254, 260, 264–265, 281, 285, 288, 312 Fiji 209 flm; 164, 165, 169; L’Age d’or 165; Un Chien Andalou 165; Spellbound 165 Florida Association for Music Therapy (FAMT) 40 forensic 210, 294 France 81, 197 Freudian theory 161–166, 168–170, 173, 178–179, 184, 189, 204, 217, 244, 254 Germany 5, 83 110 gestalt 37, 83, 84, 87, 236, 327 Good Medicine Report 85 graftti 130

368 Subject index Greece 81, 93 group dynamics 43, 48 group therapy 40, 43, 44–46, 47–48, 51–53, 57–59, 68, 78, 81, 89, 94, 96, 102, 105, 110, 113, 121, 125–129, 131, 133, 137–141, 151, 153–154, 157, 231, 258–264, 275–288, 307–314, 318–321, 321–326 Hawaii 209 Health Professions Council 60, 102 healthcare 2, 13, 14, 15, 19, 24, 31, 38, 52, 65, 68, 72, 73, 74, 75, 82, 83, 96, 97, 98, 101, 102, 103, 109–15, 118, 124, 129, 244, 292, 301, 330, 332 Hindu 59, 85 histories of arts therapies 18–28, 71–107 HIV 66, 198–199 holistic 25, 82, 116, 243, 262 homelessness 31–32 hospital xvii, 4, 6, 7, 9, 10, 15, 24, 65, 72, 74, 78–79, 89, 90–92, 96, 104, 106, 131, 134, 138, 160, 194, 203, 207, 234, 296, 302 hospital arts 65, 89, 90–95, 98, 115 humanistic therapy 12, 248 identity 12, 14, 25, 26, 36, 54, 56, 65, 82–83, 87, 98, 116, 124, 137, 147, 151, 153–155, 160, 162, 172, 191, 192, 205, 207, 223–225, 247, 254, 259, 260, 265, 267, 269, 272–275, 281–284, 297–298, 308; see also self I Do, I Undo, I Redo 167–169 image 1, 8, 22, 29–34, 37, 40, 43, 50, 54, 57, 60, 85, 95, 98–100, 105, 113–114, 120, 129, 141, 142–149, 153–155, 157, 158–164, 167–168, 173–175, 179–181, 182–187, 188–191, 201, 203–204, 216–219, 221–222, 224–235, 241–242, 251, 259–260, 283–284, 298, 302, 307, 311–312, 316–320, 322–234, 329–330 imagination 5, 40, 48, 49, 50, 115, 130, 142, 149, 163, 165, 169, 171, 181, 185, 199, 202, 204, 228, 241, 330

improvisation 9, 10, 40, 42, 44, 45, 48, 50, 55–57, 60, 69, 86–87, 117, 125–129, 136, 139–141, 143–145, 151–153, 156, 169, 177, 210, 219, 222, 231, 251, 253, 255, 256, 258, 298, 322–323 India 18, 59, 73, 81, 89, 321, 329 intercultural 124, 243; see also cultural; transcultural counselling interdisciplinary xvii, 5, 27, 83, 114, 117, 299; and evaluation 234–8 interpretation 25, 34, 39, 44, 52, 58, 83, 99, 136, 144, 149, 152, 170, 173, 184–187, 191, 226, 233, 245, 248, 253, 254, 266, 271, 297, 304, 316–320; see also meaning intuition 95, 177, 236, 271, 327 Investigacão em Musicoterapia 277 Irish Association of Creative Arts Therapists (IACAT) 50–51, 72, 74 Israel 20, 113–114, 131, 141, 217 Jamaica 74, 89 Japan 6, 25, 42, 43, 45, 67, 77, 90–91, 107, 195 Japanese Federation for Music Therapy (JFMT) 91 jazz 5, 57, 73, 84, 87 Jungian theory 12, 37, 83, 84, 87, 89, 116, 130–131, 149, 160, 163–164, 171–172, 181–182, 244, 254, 320 Kelly’s Repertory Grid 304 Kleinian theory 160, 167–169, 200, 217, 244, 245, 254, 320 learning disability 24, 29, 41, 90, 144, 285–290, 307–315 magic 115, 138, 147 mask 36, 50, 53, 151, 220, 271 meaning 19, 23, 36–37, 40, 44, 45, 50, 56, 59, 63–64, 70, 85, 115, 121, 124, 125–128, 129, 135–136, 138, 139, 142, 144, 149, 152, 170, 173, 184–187, 226, 233, 245, 248, 253, 254, 266, 271, 297, 304, 316–320 medicine 6, 65, 67, 68, 73, 75, 76, 79, 81, 82, 108, 111, 112, 117, 120, 293, 300, 303, 321

Subject index 369 Minotaure 166 Mostar Music Centre (MMC) 42 music therapy 77–82, 89–95, 253–258, 283–288, 319–321, 321–326 defnition 39–42 musical instruments 41, 152, 213, 225, 271 mysticism 39 National Association for Drama Therapy 20, 67 National Association for Music Therapy (US) 20 National Coalition of Creative Arts Therapies Associations (NCCATA) 19, 67 nazism 83, 86 neoliberalism 111 Netherlands 83, 195, 294 Netherlands Art Therapy Society 20 Netherlands Society for Creative Therapy 20 neuroscience 5, 12, 37, 43, 57, 79, 110, 135, 136 New Zealand Society for Music Therapy (NZSMT) 40 Nigeria 40, 48, 75, 76, 77–83, 107, 109, 195, 198–199 non-directive approaches 33, 36, 56, 124, 125, 126, 276 non-verbal 30, 31, 37, 39, 42, 44, 45, 52, 55, 62, 63, 144, 147, 151, 153, 155, 172, 174, 175, 190, 216, 223–226, 226–228, 229, 232, 251, 255, 258–259, 267, 289, 315, 317, 322–323; see also body; embodiment Nordoff Robbins 39, 90, 152, 255–259, 285 Northern Ireland 42, 43, 45 oblique 50, 145, 151; see also symbol object 1, 10, 35, 37, 53, 54, 64, 67, 115, 121, 122, 133, 146, 150, 152–4, 165, 168, 173–174, 186, 195, 197, 199, 200–202, 210–211, 218–221, 231, 301, 318–319; and ritual 73, 114 object relations theory 160, 168, 169, 170, 189, 205, 214, 231, 251; see also object relations theory

occupational therapy 75, 90, 94, 96, 102 Oedipus Rex 165 outcome 15, 19, 21, 49, 65, 99, 100, 116, 243, 245, 280, 290–329; see also client accounts/voice; evaluation; evidence; meaning painting 6, 29, 30, 32, 35, 38, 47, 61, 62, 67, 84, 86, 87, 92, 93, 95, 120–121, 129, 135, 137, 138, 145, 152, 154, 135–136, 158–160, 169, 173–174, 180–181, 219–223, 224–226, 229, 231, 235, 299, 309, 317–319 Parkinsonism 43 play 6, 8, 10, 35, 46, 47–50, 53, 54, 59, 60, 63, 68, 85, 117, 125, 126, 128, 130–131, 134–136, 142, 145, 151–154, 157, 160, 163–164, 181–183, 218–219, 225, 226, 228–229, 243, 249, 256–259, 272, 279, 294, 306; play shift 208–211; play space 204–207, 228–229, 242; playful state 131 play therapy 200 poetry 51, 59, 67, 165 politics 24–25, 49, 159, 165, 245, 284; see also class, client accounts/ voice; eurocentric; poverty; power; race; racism; sexism; social exclusion poverty 38, 103, 114, 195, 198, 199 see also class; politics; social exclusion power 8, 14, 24–25, 35, 49, 61, 66, 70, 72, 102, 105, 107, 108, 111, 113, 179, 183, 242–244, 252–253, 254, 259–260, 264, 271, 274–277, 279–285, 288–290, 295–269, 303, 305, 307, 310; and colonialism 82, 102 see also empowerment; politics Prinzhorn collection 7, 97 see also hospital art professional identity 3, 60, 61, 67–70, 76–77, 82, 87–88, 104, 107, 111, 237–266, 268–289; see also professions professions 3, 18–28, 28–30, 39–42, 47–50, 55–57, 59, 67–70,

370 Subject index 72–74, 90–93, 99–107; see also professional identity projection 58, 117, 163, 168, 171, 216, 248, 253, 317; see also artistic projection psychiatry 11, 68, 89, 94, 96, 97, 99, 111, 294 psychoanalysis 8, 9, 11, 29, 89, 96, 159, 164, 165–170, 188–191, 200, 228, 250–255, 267, 320; see also Freudian theory; Jungian theory; Kleinian theory psychosis 24, 98, 101, 102 psychotherapy 8, 9, 11, 21, 22, 26, 28, 29, 55, 68, 75, 96, 111, 117, 122, 148, 164, 188–191, 228, 248, 250–255, 268, 283, 293, 302, 318, 321; see also art psychotherapy qualitative paradigm 185, 208, 294, 298, 299, 314–5, 326; see also arts and science; effcacy; evidence, case study quantitative paradigm 293, 297, 300, 306, 314, 321, 326; see also arts and science; effcacy; evidence; evidence based medicine; randomised control trail race 24–26, 79–82, 197, 246, 259; and racism 25–6, 103, 197, 252, 281, 303 randomised control trials (RCT) 160, 293, 294, 296, 300, 301, 320–323, 328 referral 23, 33, 42, 63–65, 218, 249, 268 refugee 12, 37, 83, 131–133, 240–241, 261–266, 277–284 rehabilitation 19, 22, 24, 30, 31, 32, 40, 42, 78, 91, 95, 280 Reichian therapy 84 religion 26, 53, 78, 112, 140, 244 Remedial Drama Centre 94 research 160, 166, 169, 177, 188–191, 196–197, 198, 199, 203, 250–267, 277–290, 292–328 Reve d’une petit flle qui voulut entrer un camel 165 review of pictures 317–320 rhythm 24, 43, 44, 57, 60, 64, 80, 92, 122, 123, 140, 148, 153, 174,

225, 226, 230, 241, 257, 278, 284, 321, 322, 324, 331 rights 103, 198, 279, 281, 310 ritual 26, 39, 40, 45, 48, 64, 72, 73, 81, 85, 108, 111, 113, 117, 139, 225, 226, 230 rock and roll 73 role play 48, 50, 92, 93, 120, 129, 136–137, 146, 151–152, 154, 178, 219, 231, 279 Rorschach inkblot test 216–217 la Rue Surrealism 165–166 schizophrenia 24, 47, 56, 101, 102, 138, 234, 246 science 6, 8, 73, 80, 84, 108–118, 185, 229, 236, 250, 297–300, 307, 326, 328, 330–331; see arts and science self 19, 29, 45, 50–51, 54, 56, 57, 63, 81, 84, 99, 114, 152–153, 155, 158, 160–164, 166, 172, 191, 192, 205, 207, 223–225, 247, 254, 259, 260, 265, 267, 269, 272–275, 281–284, 297–298, 308; and selfawareness 19, 23, 28, 31, 36, 37, 43, 45, 49, 54, 57, 110, 160–161, 188, 304; and self expression 19, 25, 30, 34, 44, 66, 92, 97, 169, 192, 223, 230, 258; and self esteem 28, 31, 37, 39, 44, 47, 49, 51, 54, 57, 304 Sesame 50 sexual abuse 144, 227 sexual orientation 244, 246 singing 5, 43, 44, 64, 78, 81, 122, 141, 153, 225, 240, 324; and song 40, 44, 64, 73, 82, 134–136, 141, 157; and yoik 122–124 social constructionism 49, 299, 303 social exclusion 49, 195, 199, 224, 245, 261, 264, 279, 303, 315 society 24, 26, 38, 41, 49, 61, 78, 79, 82, 84, 85, 103, 112, 121, 122, 128, 174, 224, 243–246, 254, 264, 275, 284 Society for Music Therapy and Remedial Music 77, 90–94, 107 South Africa 3, 25, 60, 79, 102, 103, 107, 125, 132, 195, 197–199 South America 6, 20, 28, 41, 77, 89, 91, 107, 109, 197, 207, 277 South Korea 3, 20, 24, 60, 67, 320

Subject index 371 Spellbound 165 Spirituality 25, 26, 40, 45, 80–83, 86, 112, 116, 121, 139, 229, 306 spontaneity 5, 48, 50, 86, 87, 126, 130, 136, 208, 211, 229, 298, 304, 306 Standing Committee on the Arts in Prisons (SCAP) 22 Stop the Violence 32 story 10, 48, 50, 51, 53, 121, 138, 144, 151, 155, 174, 183, 210, 218, 224–225, 232–233, 259, 302, 303 stroke survivors 30 structure of arts therapy sessions 120–141, 202–205 substance abuse 66 surrealism 6, 74, 87, 164–166, 169 symbol 26, 30, 37, 50, 51, 55, 58, 68, 74, 99, 121, 122, 125, 144, 170, 186, 189, 192, 200, 202, 203, 206, 210, 223, 226, 227, 230, 244, 251, 263, 266, 267, 278, 283, 311, 317, 323; see also image Taiwan xvii, 3, 21, 246, 295 theatre in education 66 therapeutic relationship 237–267, 268–289; and dialogue with analytic psychotherapy 250–255; and dialogue with a developmental approach to therapy 255–260; and dialogue with a mindfulness approach to therapy 260–266; and dialogue with different therapeutic paradigms compared 266–268; and client and arts therapist: traditions and discoveries 270–291 therapist role 247–269, 270–291 therapy space 15, 37, 49, 56, 124, 128, 129, 132, 137, 140, 146, 156–157, 171, 172, 177–178, 180, 191, 192, 196, 205, 207, 211, 214, 225, 228–229, 249, 260, 267–268, 270, 273, 274, 289, 290; see also play space training 3, 4, 7, 18, 20, 25, 37, 60, 61, 67, 68, 74, 78, 79, 91, 93, 96, 101–106; and arts therapy clients 127, 128, 139, 140 transcultural counselling 254; see also culture; intercultural

transference 33, 154, 180, 184, 187, 190, 191, 231, 243, 248, 251, 254, 264, 268, 318–319, 323, 329; see also countertransference trauma 22, 29, 31, 32, 37, 74, 76, 99, 144, 145, 160, 203, 217, 224, 227, 261–265, 277–284, 317 triangular relationship 29–30, 33, 35, 38, 45, 58, 100, 120–121, 135– 136, 141–146, 215, 216, 219–221, 245, 264; see also therapeutic relationship Turkey 217, 224, 227 unconscious 6, 8, 9, 10, 55, 57, 78, 87, 99, 112, 142, 143, 148, 149, 158–193, 194, 206, 207, 223, 225, 251–155, 264, 274, 296, 289–199, 316–320 United Kingdom Standing Committee on Arts in Prisons (SCAP) 22 United Kingdom Standing Committee of Arts Therapies Professions (SCATP) 41, 99, 100 United States Administration on Aging 57 United States National Expressive Therapy Association (USNETA) 20 The Unsilvered Mirror 158 Urban Bush Women 56 video 117, 152, 174, 175, 199, 231, 279, 285, 311, 314–315, 329 virtual art therapy studio 30, 261–266 voice 39, 50, 134, 135, 152, 176, 223, 228, 273, 275, 324, 329; see also client accounts/voice; singing; song; yoik war 62, 74, 77, 90, 112, 166, 277–284 West Africa 279 witnessing 174, 180, 189, 191, 203, 209, 215, 216, 219, 222, 225, 230–235, 251, 253, 263, 273, 280, 282, 316 YAHAT (The Israeli Association of Creative and Expressive therapies) 20 yoik 122–124