Abstract
Thinking is more interesting than knowing but less interesting than looking (Goethe).
On 23rd June 2009 I took up a newly created post as Head of Arts Therapies in the Forensic Directorate of an NHS Foundation Trust, clinically appointed to the brand new specialist Learning Disabilities service. I walked into the ward, a complete stranger. I saw the newly decorated rooms, new furniture, a new television - that had already been broken, and some unfamiliar faces that seemed to be expecting me but I had no idea who they were. I was offered tea, a few friendly words, and lots of smiles, then I realized the ward had a full complement of patients wandering about looking how I felt; lost, uncertain, bewildered. It slowly dawned on me that the new team had arrived to work with a ward of patients and none of us had a clue what to do first. Nothing had been set up, it was a blank sheet waiting to be filled with colour, shape, form and feeling.
As a multidisciplinary team we huddled together wondering how to devise seven days of activities, week in week out. What were our resources? Do we have any money? Here, the consultant, specialist doctor, social worker, speech and language therapist, occupational therapist, psychologist, music therapist, art psychotherapist, modern matron, educator, specialist nurses, bank nurses and social therapists all sat poised for action in the complete unknown. Meanwhile, a group of frustrated, anxious, bored, terrified and disturbed patients ran riot, each performing their own daily routine of behaviours communicating whatever they needed us to know. Exciting? It was daunting and strangely fascinating.
Something had to be done so it was decided we could draw a map. Getting some large sheets of paper, sticking them together and drawing ruled lines we created a timetable. It looked simple but was very complicated. Do we say what we are doing, or what we want to do?
With very good intentions intact, the music therapist and I decided to join forces in devising the first ward group, which was to be open to all patients every Monday. It was to be held in the group room on the ward, which was more of a large table and chairs surrounded by walls. With no materials or instruments at hand, I borrowed some felt pens and paper. We were ready; and waiting.
No patients arrived; no one was interested. Some appeared slightly curious, but unimpressed when they saw what little we had to offer. There we sat each week…alone…waiting…. staring at empty tables and chairs with just the cleaners’ looks of pity to spur us on. Nurses tried to encourage the patients, but with no success.
Sitting on my own with everyone outside, I heard busy staff and occupied patients wandering up and down the ward, drifting and meandering like a school of basking sharks. I sat drawing the empty space, or drawing the patient who did join us for a sleep; like horses waiting to unfurl we held on to the potential. Then, I realized what it was like to be these people. The world and society moving around purposefully, up and down, whilst they sit in a space…often alone…waiting. Is anyone going to take an interest? Do they have a purpose? What’s our purpose?
This was not conscious, but I had a gradual realization of my soaking up the emptiness. This felt very different to my previous experiences with patients with disordered personalities who found ways of communicating: “I take control by doing something so you can’t do anything because I’m making you do something because of what I’m doing”. Here it was different; the patients with learning disabilities were communicating: “I take control by doing nothing so you can’t do anything”. I felt totally disempowered. Fortunately, over the weeks lovely art materials and beautiful musical instruments arrived and everyone thought it was their birthday. The music therapist and I rounded up a group of patients by singing our invitations and observations. The patients thought we were strangely fascinating and quite mad, but it worked.
I have since discovered the need to be open to many different ways of working. This is one of the most rejecting client groups I have ever worked with, characterized by intense ambivalence and lack of insight, this work calls for flexibility and creativity and a determined sense of never giving up. In adapting my practice, I found myself with a highly resistant patient playing baseball in a group, with a large rolling pin and ball of clay in an attempt to help him engage, finding he is a good batsman and I’m better at throwing. I’ve chased patients around the art therapy table in an attempt to bring life to role play by using humour, being playful, being prepared to listen to music at the worst moment when I’m trying to close down a session, and exploring in cartoon form the most painful and sensitive issues of sexual offending. Substituting the victim and perpetrator with the popular cartoon characters ‘Squidswood’ and ‘Spongebob’ Square Pants’ proved to help the patient relax his defenses and discuss his transgressions.
Gradually and totally non-psychoanalytically, but with traces of psychodynamic interfacing and patient centeredness, a group formed. The men made a choice to take up the invitation to become members of a group that wanted them and that they wanted to be a part of. They wanted to engage and share the space with others, and to use art making and the art materials provided.
Five years on and with a slowly changing population, the group is now set in the weekly timetable with a regular attendance of up to seven members at any time. The men have become a group of skilled draftsmen who see the process as ‘going to work’. It has a point and they have some kind of fascination in one another. It is irrelevant whether they can draw, and to a certain extent, what they draw. The task is to find a way of being in the same room together at one end of the spectrum, and to find some cohesion at the other. The work is as exhilarating as it is exhausting.
It can be a struggle for offender patients to connect on an emotional level, and images can bring up intense feelings of loss and failure only safely explored with the most skilled of supervisors. I came to realize the relationship with the therapist might be the only kind of relationship with anyone. The therapist can bring a positive attitude to the problem of challenging behaviour in the group, which can have a knock-on effect for staff when they can see concrete results, such as in the images. This can sometimes change professional assumptions about what insight and understanding patients may or may not have of their own risk.
Working with people with intellectual disabilities in a locked setting is like working in the dark. It can stretch the skills, flexibility, and imagination of therapists facing barriers with learning-disability-offence related work, and can limit the use of traditional techniques and ideologies. Fortunately working with patients with learning disabilities has been the bread and butter for art therapists since the birth of the profession in the 1940s. Therapists have had to develop novel approaches to meet the needs of clients. It’s been a natural path to non-verbal creative treatment, as art therapists have never faced the obstacles faced by verbal therapies; the obstacles of not being recognized as a valid treatment option. Arts therapies are the treatment option, maybe by default?
Initially I began my practice in forensic learning disabilities with plenty of experience working with violent offender patients, and I was aware that I had developed a high threshold of tolerance for fear, anxiety and disturbance. The co-facilitator and I found patients to work with by announcing who we are and what we are doing. We then rounded them up, singing like travelling minstrels, hoping to provide a playground where we could play, be hands on and get our hands dirty. We wanted to find a way of not being repelled whilst getting close to the repellant in ourselves, to sit with the vileness of their crimes, behaviour, lack of personal hygiene, the dribbling, the smells, the dirt – this being the way they repelled people as a means of avoiding intimacy. As group workers, we thought about how to get close to the ‘smelly kids’, how to help the smelly kids get close to one another, and how not to deviate from the task -whilst not being entirely sure what the task was.
In my approach I found I had to develop a means of working flexibly, creatively and playfully, taking on many roles in becoming a playmate, authoritarian, teacher, confidant, co-smelly kid and deviant; yet I found myself alone with my ideas. It seemed vital to combine others’ thinking with mine for validation. There seemed to be no template for me to follow, I was discovering a way of working for myself by using my thinking skills, drawing skills, sense of humour, and art materials in a way they are not conventionally used. I had to be willing to become all things to form an alliance. I found I had to feel helpless, to be disempowered and dependent and to let the patient take control. I had to get ‘close’ to the child/adult, victim/perpetrator, ‘SpongeBob Square Pants/Squidswood’ binary paradoxical states of mind, and I had to become the appropriate playmate that they never had to form a healthy relationship.
Rather than exploit the situation, it was important to be there as a boundaried container, taking on different roles as if ‘partners in crime’. To this end, I had to acknowledge my own disabilities to become subversive, get covered in the saliva, and show my disgust after building up enough trust to ensure the patient knows they won’t be rejected. Sinason (2011) describes the disgust response as infantile and innate; it’s the flip side of fascination and suggests we have to look into it to find something that moves us. We need not to judge the deviance but to understand it. My way was to substitute cartoon characters for the most sensitive of roles, to not take the subject lightly, but to use my illustration skills to find a manageable way of not re-traumatizing the patient. Alongside this, I found it vital in forming a therapeutic alliance; to being friendly, warm, approachable, accessible, funny, serious, empathetic, open, alive, real and authentic to the experience.
Wolfenberger (Manners, 2005, p. 7) describes how individuals are perceived as deviant due to their differentness and lack of real emotional feelings. (Kuckaj, 1990) McKenzie, Chisholm and Murray describe how they were met with an institutionalized resistance to work psychodynamically with clients who had learning disabilities. They stated: ‘People with learning disabilities often find themselves disempowered when in a relationship with a helping professional, they are often required to perform difficult tasks for the psychologist or teacher etc.’ (2000 p. 5) From my own experience I found patients had been tested and re-tested, yet the teamwork uses a person centered approach and integrates the recommendations of bespoke treatment from the 2008 ‘Valuing people now’ report. This seems a vast move from just ten years ago when Kuczaj states, ‘perhaps the structure that clients and staff find themselves in helps perpetuate this denial of feelings, along with the staff inadequacies in ward situations which have prevailed until quite recently. The denial has a historical background, but is also linked with the prevalent assumption that a more limited cognitive capacity indicates a more limited emotional capacity’. (1990 p. 117)
There is a great breadth of uncertainty and a need to question ones motives for this area of work. Given that there is little sympathy for the offender and an opinion that paedophilia is an addiction (something one can snap out of with self-discipline and will power). Is there a lack of willingness to tolerate this part of society? Does societal stigmatization lead to self-stigmatization and increase the difficulty to integrate offender patients with learning disabilities back into the community? With the drive to implement the Recovery Model there is also a drive on patients throughout. In some ways this can help reduce institutionalization if people can be returned sooner into society, but does society want them back?
The members of the art therapy group are all too aware that they are very low down the ranks, and often feel better off and safer in the hospital. It can create confusion when they are told they are better-off in the community .The images made by patients in the group project their anxieties about ‘moving on’; usually including depictions of solitary tropical islands surrounded by sea, blissful isolation, or previous homes in high security where they were kept well away from society but also a symbol of care, and paradoxically of abuse.
I have had experience with a patient who spent many months building a house from ice-lolly sticks to create a symbol of self in the form of a psychic space and a place to move from. This therefore represented increased flexibility, as it acted like a shell that provided a holding protective layer but also an osmotic function with movement – in and out. He needed to do this work in a form of pre-therapy before he felt safe enough to join the group, but also to have a place to speak about his damaging experiences in his community where he was treated as an outcast. He feared similar retribution from the group who he saw as a mob, so needed to build up the confidence to be with other people in the safe and familiar space of the art therapy room.
I experience many challenges in this work, which are well described and documented in the literature. These include dealing with patients who resist any form of therapy or who do not identify themselves as having a problem, and those who suffer from poor memory retention and a fear of rejection if their offences are exposed to others. (Aulich 1994) There is another theme of patients gaining the ability to articulate their distorted thinking through therapy to increase avoidance and control. Added difficulties are that without therapy, sexual fantasies may spiral out of control, and that facilitating thinking through interpretation may be too painful for both patient and therapist, and are therefore avoided. Equally difficult is the capacity to understand emotional difficulties and needs, as their emotional needs have been, until recently, ignored. (Hagood, 1994 p. 67, Tipple 1994, Stott and Males, 1984, Kuczaj, 1990) There is another problem where patients may be reluctant to use art materials, either due to physical difficulties to perform everyday tasks or because the experience makes them feel childish. (Hagood, 1994, Stott and Males, 1984, Kuczaj, 1990, Aulich, 1994, Manners, 2005) Authors also discuss the element of control and the patients need to control their world or to have control over something; perhaps by doing nothing. (Rothwell & Hutchinson, 2011) This is a defense frequently used by patients in my work. The image and space is used to maintain control by making diagrammatic images that distance the therapist, have control over art work, control over another, control over the session and the therapist, largely as a means of experiencing feeling powerfully potent. That confrontation can cause feelings of helplessness and humiliation. Therefore tactics used to defend against this may include de-roling, deskilling and humiliating the therapist. By having so many needs and persistently negative experiences of relationships can cause the therapist to feel the loss and failure. (Hagood, 1994, Kuzcaj, 1990, Willoughby- Booth & Pearce, 1998, Aulich, 1994) However, Manners argues that the psychodynamic model reinforces the power struggle of the therapists’ knowingness and clients’ not-knowingness. (2005, p. 67)
Forensic patients with a learning disability are often exposed to ‘trauma work’, with little understanding of the impact of trauma or what it is to be the object of abuse or to abuse. This can be equally traumatizing, and those linking thoughts and memories can lead to trauma and pain. Sinason (2011) identifies trauma at the root of pain and hurt and acknowledges the importance of creating a space where it will be heard and where something can be built and constructed to help something happen. She describes the development of a new constituted family where there are opportunities to learn to be fascinated, to be respected and to care. The challenge is how to bear the pain and not pass it on to others, for example, through heightened sexuality as a defense against trauma, or through ‘enactment] the pain of early trauma on those children who are viewed as perfect, unflawed and non-disabled’. Suppressed sexuality can be explosive and patients are enacting the worse elements of their experience, and their abuse, causing a valiant desire for hurting the damaged, dependent and traumatized unconsciously, and are therefore vulnerable to be re traumatized and exploited. (Corbett 1996, Hopper 2011, Sinason, 2011) This can make group work very slow paced and creates a need of safe boundaries to hold and acknowledge the emotions imbued in trauma work, holding the victim and offence in mind simultaneously.
Group vignette:
An ordinary day and there are five patients waiting to go to the art therapy group. A psychology trainee asks if she can join us and a social therapist is given the duty of co-escort. The trainee asks for a brief over view from the therapist who then attempts to summaries a process and an historical context of the life of the group that is in fact beyond a pithy explanation and tells the trainee all will be revealed once she has experienced the group. The collection of eight people make their way through the buildings unlocking and locking doors, on a journey repeated many times before to the art therapy room. Some comments are exchanged to pass the time but generally everyone knows the routine. Once in the room the therapist opens the cupboard to the art materials, patients retrieve their folders or select paper to work on. Everyone in the group instigates their own activity and finds somewhere to sit at a large table.
Initially there is silence as people settle down to focus on their work. At either end of the table sit two patients side by side, at one side sit the trainee psychologist and the social therapist, on the other sit a patient and the art therapist. No one asks what to do. They have already begun. The therapist puts up a large black and white laminated poster of a ‘Blob Tree’. She is ignored.
One patient draws a green monster and asks the therapist what it is? A big lizard comes the reply. No, it’s a dinosaur comes the answer. This patient often draws scary things with large teeth. He shows the trainee who gives some positive regard. He then draws a flying dinosaur he knows the therapist will recognize from their trip to the Natural History Museum, unfortunately she’s forgotten what its called but he reminds her given his incredible catalogue of dinosaur information. He then starts complaining that staff are stingy and won’t give him coke or chocolate and pretends to cry. The therapist has been through this routine many times previously and knows not to mention the word ‘diabetic’, (this word he will depict as ‘killer bees’ and they have to be killed by a man with a big flame thrower when they become ‘dead bees’. Phonetically ‘die a bee tees’) instead she goes into a repertoire of reasons why super heroes don’t eat chocolate, fizzy drinks and crisps. The patient knows the answer but asks why? Because they won’t be able to fly off the ground, they’ll be too heavy, they can have a bit of cake though. This pacifies the patient who returns to his drawings and produces a ‘ghost with shoulders and a round face’. The therapist reminds him of the ghost family he drew recently. He looks pleased to have the image remembered and begins muttering ‘ghost family’ under his breath then looks through his bulging folder.
The patient sitting nearest the social therapist can’t concentrate on his own work and takes delight in the social therapist’s image by naming the characters rapidly. ‘It’s a man, who is it? A dog, its funny, who is it? A bird. What have you drawn’? The social therapist benignly replies hat he doesn’t know and it doesn’t have a name. The patient beside him is very carefully drawing a flag and has a neat little self-contained palette of watercolours. He says he is drawing the flag of his country but can’t remember the colours. Another patient from the same country reminds him it is black, gold and green. This patient is new to the ward and to the group. It has been noted that new members often start with a drawing of the flag of their country possibly to help their orientation and give them a place to start. It also identifies their difference and on occasions has been the inspiration for very rich discussion on people’s origin and heritage. This can lead into a discussion on race and belonging. The therapist will stimulate a form of introduction ‘culturally speaking’ to initiate a new means of getting to know one another’s differences.
The more quiet patients are sitting together quietly drawing and painting but one of them chooses to show his image and states it’s a truck, a jumper and an aeroplane. The therapist struggles to hear what he is saying and thinks he is saying ‘shark’, the patient is very tolerant and repeats ‘truck’, the social therapist helps out as the therapist is confused and says it looks like a vehicle not a shark. She is then told that’s because it’s a truck. The patient makes no explanation for what he has drawn. He has been attending the group for a couple of years and has made good progress since before when he would attend the group but would refuse to return to the ward and emergency nursing assistance would be called to carry him back if he refused to walk. He would also lock himself in the toilet or just run off to the other end of the corridor. Now he sits and draws with no need to run. He also takes in everything being said despite saying very little. The responsive environment of the ward has enabled him to become ‘human’ and socialized. He can be provocative to other patients but in his artwork he has matured developmentally from latency to adolescence. This is visible in his imagery as his sense of self takes form having moved from painting very indistinct shapes that covered the paper to creating highly individualized figurative work.
An even quieter patient, who read the dictionary as a means of being in the group, has been drawing competently and colours in his depictions of his ‘lucky numbers’. Each week he reveals a little bit more about himself, becomes a little less withdrawn and a little more self-exploratory. The therapist has to be mindful to hold him in mind as he can easily drop off the radar. He wants to share his work but would never initiate this action. He is encouraged and willingly shows what he has drawn. Others start naming their lucky numbers. In the middle of this the curious patient asks to use the toilet. ‘This is facilitated by the social therapist. Whilst he is out the dinosaur-drawing patient begins a familiar game with the therapist of what’s the colour of…? This is where he repeatedly asks the colour of something and colours are named. This time the question is ‘what’s the colour of the desert’ now asked to the trainee. The trainee goes into therapist mode again by returning the question on him. He looks a bit bewildered and dissatisfied.
The therapist knows the game so begins naming colours. At the end of the list he triumphantly points out her stupidity for leaving out the colour black and gives her a sideways look with a grin, his eyebrows shoot up in amusement. He then starts asking the trainee about her picture and again she starts putting the questions back to him. This gets him nowhere but as he tends to enjoy the company of the new young female trainees that have filed through the service over the years he preservers by drawing a ‘troll monster’. He then asks her to write ‘troll monster’ and she begins to oblige until the therapist points out he is perfectly capable of writing this himself. He agrees then starts a new game of ‘where do troll monsters live’? The trainee looks bewildered and states she doesn’t know. This goes on for a bit until the resounding ‘PECKCHAM’ sails through the air from the curious patient who has returned. The group falls about laughing, much to the curious patients delight, it is then agreed that’s where Troll Monsters come from. The patient asks the trainee the same question and she confidently replies with ‘Peckham’.
The therapist has been drawing fruit and vegetables in blue felt pen and holds it up whilst asking the curious patient to name the individual objects. He has a low IQ and the developmental ability of a four year old so the team is assessing his learning abilities and what cognitive knowledge he has, knowing it is very poor due to childhood neglect. The therapist has also established that he’s never had sleep training and tends to oscillate from manic over tiredness to instant drowsiness when he feels safe and contained. By making her voice more soporific he will easily drop off to sleep in the groups whilst listening to the therapist speak. Its been suggested he is read a bed time story to help him sleep better and get into a routine.
So far he is doing well naming the fruits and can say what ones he likes to eat and what he doesn’t like to eat. He has drawn numbers from 1 to 10 and can name them in correct chronological order. This is hopeful as he is due to start the Sex Offender Treatment Programme soon and will then be discharged in six months. It is important he gets as much therapeutic input as possible in the mean while.
The group comes to an end and everyone begins to pack away the art materials in the cupboard, put their work in their folders then return them to the storage area. A couple of images are placed rather arbitrarily on the nearest shelf but having been spotted by the therapist she asks them to put the work away properly so it can be kept safe. The group returns back to the ward safely and is thanked for using the session so well. The trainee debriefs with the therapist and says she now realizes why it has to be experienced and how hard it is to explain what happens. Something does happen it’s just not clear what.
Discussion
Patient experiences are paramount to gaining a view of what it is to be someone with a learning disability, to see how the learning disabled are viewed in society, and to further appreciate how patients come to express themselves and communicate in particular ways in the group. Change can be very slow and there is much dialogue about the need for a learning disabled person to protect themselves from the judgment of others and the lack of early stimulation or bonding, but also a resistance to relinquish familiar habits brought about through a core complex of being born with a learning disability. (Kuczaj, 1990, Hawtin, 2009, Corbett 1996) Corbett describes this well stating: ‘our clients tell us of the deep, inner pain when (that attunement is misaligned, when (that) mirroring is distorted by a primary fear and rage at the disability itself. Certainly for the offenders with whom we work, some chaotic attachment patterns may produce mirroring of the core complex’ (Corbett, 1996).
I wondered if this is akin to an experience of ‘being born deviant’ in the eyes of society, when I found myself waiting and waiting for patients to make use of the art therapy group. It put in my mind a sense of my having to ‘do’ something deviant for something to happen, and also to consider the meaning of the action of doing something.
Is it to be noticed, to evacuate frustration or to get help? Perhaps the act of deviance/defiance may then cause something to happen? From my experience of violent offender patients - including those with a learning disability - when they are trusted they do not behave violently. Sinason puts an interesting slant on this by saying that patients become or create in themselves the person they fear, and that trauma-based work allows for a different way of being (Sinason, 2011).
The role of art therapy in group work, and the therapist’s skills feature predominantly in relation to the therapist’s skills as an artist and the weight of keeping an idea or thought alive. Likewise, that drawing ‘alongside’ with and for the patient is an essential aide, as is the use of a more concrete approach to enable patients to internalize and think about what’s been happening whilst feeling held and contained.
Tustin (1990, p. 47) states ‘such patients need to feel that there is a nurturing person who cares deeply whether they live or die and who affirms their existence by talking to them as if they exist.’ (Stack, 1996 p. 11) There appears to be elements of the therapist’s role that are specific to working with learning disabled people. For instance, the use of symbolization is rarely contrived, attention seeking or second hand, and a client’s ability to cope with discussion of the artwork must be considered. Work can be both directive and non-directive and neither approach will detract from the individuals worth or capabilities, but in one case example it was shown how drawing was the only way to pacify one clients difficult moods. (Gray, 1985, Stott and Males, 1984) The art therapist is also described as an ‘enabler’ or ‘witness’ whose role it is to play, and the experience of being utilized by another distinguishes this work. (Willoughby-Booth and Pearce, 1998) Other views see the therapist as the auxiliary ego taking on the role of staying in touch with aspects of the self one would prefer to detach from, as in dissociation, and additionally to establish empathy and to become curious, affectionate and open to the need for ‘ordinariness’, rather than searching to become ‘normal’. It is to tolerate the unbearable imprint from childhood, and yet to provide friendliness, compassion, encouragement and positive reinforcement; to work at the persons pace and help them reflect on the content of the artwork to gain insight and overcome difficulties. (Hopper 2011, Sinason 2011, Stott and Males 1984) There may even be a crossover of the therapists’ role to be actively involved in social inclusion activities, going for a walk or an outing. This is the case on the ward I work on where, regardless of the staffs’ banding, hierarchy, job description, all hands need to be on deck, so to speak. Manners (2005) sees the role of the therapist to act as a conduit between internal and external worlds by considering the patients social context and the counter transference phenomena, as does Sinason, who points to the social and cultural context of violence for patients (2011). Moves away from a focus of unconscious drives and past relationships are now described by therapists as focusing on ‘immediate exchanges’ in the here and now between the client and therapist. (Tipple, 2003 in Manners, 2005 p. 69) This is reiterated by McKenzie, Chisholm and Murray (1997) who, in referring to Tipple (1994) see more of an interpretive and directive stance taken by the therapist than in other forms of art therapy; facilitating emotional expression to ameliorate psychological distress. (p. 63)
The task of the therapist is seen as to encourage self-esteem and self-development, to help individuals achieve in accordance with their individual development, and to have a gentle approach and low expectations of space, time, attention and continuity (Kuczaj, 1990). Hawtin (2009) describes the art therapist as offering a different way of thinking. They want to understand how the person views the world and how they feel, their role being providing a non-verbal expressive space.
The focus of the therapy and the approaches used appear very broad, and incorporate group work ranging from a closed group using emergent themes and dry materials (Manners, 2005) to a themed group focusing on positive aspects of self, as in my own work with sex offenders. Many authors point to the structured nature of their approach to provide the holding environment for the safe expression of anger, rage, and frustration and fear in a harmless and potentially traumatized manner. (Kuczaj 1990, Willoughby-Booth, 2009, Aulich, 1994)
Art therapists may need to employ several complementary approaches and techniques, and may use art making with the person, working alongside the person offering sessions outside the studio, altering the length and frequency of the sessions or not, thereby both being boundaried but creative, flexible and attuned. Therapists’ skills of being deeply empathetic and exploratory are essential, as is counter transference awareness in order to confront, challenge and interpret; whilst being tailored to the emotional and cognitive needs of the client. Themes in the approach are shown to be helpful in engaging patients to explore their use of fantasy, evoke memories and emotions, and to raise further themes, and are seen as giving back power that patients have experienced never having or had and lost. (Hawtin 2009, McKenzie, Chisholm and Murray 2000, Tipple 1993) It is stated that although a learning disability cannot be cured, art therapists can offer a specialist skill to enable the development of empathy and to find a safe way of expressing hurt, particularly for violent men who are traumatized. (Aulich 1994, Sinason 2010, 2011)
In developing an art therapy group I was aware of the task in hand and the importance of a structure everyone in the milieu could hold on to. The art therapy group has become one of the pillar groups in a weekly programme to enable the men to learn how to be in therapy. The core weekly programme consists of a community meeting for the whole ward; a social tea group where patients and staff can sit, drink tea and socialize together without any particular agenda.
There is a discussion group, a men’s health group, a baking group, a reading group, psychology groups, a music therapy group as well as art therapy groups. These groups all form a matrix that underpin the programme to suit the varying abilities of the patients and to make group work accessible for the most disabled to the higher functioning. The groups form a care pathway of pre-pre groups, pre-groups and therapy groups from the time the patients are admitted on to the ward to the point of discharge. The groups are planned to enable the patients to progress through the system from medium to low security with the opportunity to gain escorted leave with a staff member to unescorted leave when the patients can take up voluntary work in the community, attend the local gym or go to college.
Each group will take on the mantel of enhancing the patient’s progress to help them become more socialized, to reduce or moderate their risk and to help them become people with a purpose. The art therapy group is just one of the groups that can fulfill this task in conjunction with other groups. The facilitation of the groups is largely interdisciplinary, as joint working is strongly encouraged as a means of developing a community approach and to maintain consistency. The art therapy group is no different and will often be supported by social skills therapists, nurses, trainees and consultants. I have even had CQC inspectors join in to get first hand experience of what it’s like being in the group. Everyone is encouraged to make artworks and to use the art materials. The group members often find making art together gives them another way of communicating and finding commonalities not easily evidenced on the ward. The ‘us’ and ‘them’ dynamic are diluted, facilitating a group led, rather than a facilitator led, group.
The Learning Disabled patients’ experience is paramount to gaining a view of what it is to be someone with a Learning Disability and how people with Learning Disabilities are viewed in society. It is also vital to further appreciating how patients come to express themselves and communicate in particular ways. The image as a containing vessel for destructive emotions and thoughts is picked up by Pearce (2004), Willoughby-Booth and Pearce (1998), and Stott and Males (1994) and the existing research provides positive rehabilitative indicators in the reduction in recidivist activity for the use of art therapy with offender Learning Disabled patients. It suggests group work and reflection are the most effective elements in treatment.
Art therapy with Learning Disabilities has been pioneered since 1969 when the first article was published in Inscape, (an International Journal for art therapists published in the UK), by Cortazzie and Gunsburg (1969), who discuss the patients experience in a large asylum type institution.
Willoughby-Booth and Pearce (1998) emphasize the importance of ‘object survival’ (p. 65) represented through art materials and objects made at different stages of the patients’ developmental journey. Stott and Males (1984) say the role of art therapy is to reinforce a sense of self, self-confidence and enhanced communication through self-expression, by offering specialist skills to ‘normalize’ (p. 114) people with a Learning Disability and mental health problems (p. 115). They also reiterate the emphasis on working at the persons pace and setting their own goals in line with their developmental stage. By linking mark making and thinking, they suggest the need for Child Observation techniques to contextualize symbolization in reference to an individual’s cultural experiences. Elements of the therapist’s role that is specific to working with learning disabled people identified by Gray (1985), Stott and Males. (1984) Rees (1995, 1998) state the need to consider the huge variation of disparate need in the field of Learning Disabilities through writing and research, and acknowledges the expansion of knowledge in the art therapy arena with this client group.
There is a change in direction in the work of art therapists in the new millennium, where psychotherapeutic approaches are combined with a debate on the role of the art therapist, the therapeutic space and the development of group work. Manners (2005 p. 67) discusses his work using an art therapy approach with a group of learning disabled men detained under the Mental Health Act (1983). He develops his view that the psychodynamic model can reinforce power struggles connected to the patient’s sense of disempowerment and helplessness through lack of choice and staff responses to challenging behaviour. This he links to the patient’s experience of being removed from society into institutions, and strongly argues that the role of the therapist is to act as a conduit between internal and external worlds by considering the patients’ social context and the countertransference phenomena.
Aulich (1994) writes about the role of art therapy for violent and traumatised men, many with unacknowledged Learning Disabilities who are sex offenders. She sees the art therapists’ ability to offer specialist skills to enable the development of empathy and to find a safe way of expressing hurt. Working directionally with groups Aulich also emphasizes the link with issues of control and power and how the loss of potency promotes feelings of helplessness and humiliation. Aulich sees art therapy as having a learning function where individuals gain insight from their internal emotional world and can use this process to gauge the patients continued risk and level of ‘dangerousness’.
McKenzie, Chisholm and Murray (2000) describe running a group for learning disabled offenders with the goal to prevent further offending through the facilitation of emotional expression by using an approach not dependent on verbal communication. Evaluation throughout treatment confirmed results that none of the participants were charged with re-offending during the course of the group.
They state that ‘the skills of the art therapy profession clearly lie partly in the facilitation of emotional expression and amelioration of psychological distress by means which do not rely solely on the verbal abilities of the client’ (p63), and identify the ultimate goal of treatment as being preventative of re offending and that the patients understanding of the ‘why’ they offended is secondary. (p63) McKenzie, Chisholm and Murray discuss the particular susceptibility of people with Learning Disabilities to becoming victims of sexual abuse, and point out the over representation of this population becoming perpetrators compared to the general population by citing McCarthy and Thompson. (1997) Largely the authors’ research identifies the need to adapt the group work for Learning Disabled offenders in order for them to engage in treatment by using multi-modal interventions, including Cognitive Behavioural Therapy. (O’Connor 1997) This research takes the form of group work over two and a half years and seems to replicate the Sex Offender Treatment Programme now endorsed through recognised SOTP trainings, which focus on techniques with cognitive distortions. The format described is a weekly group lasting sixty to ninety minutes run by a male art therapist and female psychologist, who enabled the participants - all male - to explore how they were feeling through a warm up exercise related to the theme of the session. This was followed by a main art-based activity and discussion on the theme and ended with another check of how the individuals were feeling, with the aim of accessing areas identified as important to sexual offending. (Bowden 1994 p64) In recognition of the research, individual sessions were offered to look at difficulties in more detail. (p64) The researchers state the group had some success, measured by the decrease in patients re offending rates, which was evaluated through performance in a group setting, changes in knowledge, attitudes and cognitions, and behavioural change. (p67) So far this is the only specific research published relevant to my own area of interest until Manners took up the mantel for art therapy with Learning Disabled sex offenders in a secure setting in 2005. Manners states that his research highlighted power imbalances faced between patient and therapist and an importance of considering the social context of the work (p69), and reflected on whether the psychodynamic model reinforced the power structure of therapists knowingness and clients not knowingness. (p67)
Pearce (2006) researched the link between Personality Disorder and Learning Disabled patients who have committed sexual offences. Using a focus group to explore the experience of art therapists working with dual diagnosed patients to inform the effectiveness of art therapy with this client group, she concluded that one outcome was an unexpected factor that art-making materials enabled reflection to become possible.
The most recent and yet unpublished research comes from Dr S. Hackett who researched Art Psychotherapy with Adult Offenders who have Intellectual and Developmental Disabilities (2012). This study shows qualitative results for service users with Learning Disabilities, and found the artwork helped patients to process thinking, personal reflection and ability to mentalize, thereby evidencing a reduction in the patients’ levels of aggression.
The weekly group
This last piece of unpublished research mirrors the work of my art therapy group the closest, and puts an emphasis on valuing what the patient can do rather than what they can’t do. The group members can discover new talents and find what they are good at, that they do have talents and that they can learn how to appreciate one another’s work and have their own work admired, appreciated or explored further through discussion. The group itself has a role modeling function. For instance: the dinosaur drawing patient constantly washes his hands for no obvious reason. Here the group will ask him to sit down and continue painting by showing their interest in his work. The quiet but all observing patient starts discussions by posing questions like ‘why are women not happy being raped?’ The other quieter patient enjoys reading a dictionary in the group and has become known as ‘Dictionary corner’. He will read the meanings of words being discussed at the time to help better understand the words being used. It is also a way for him to negotiate being in a group with others, and managing to be part of something, whilst allowing him to connect and disconnect should the need arise. Some questions can seem provocative but they also validate the trust built up amongst group members and the therapists, who can be depended on not to shame or judge members asking the questions they genuinely do not know the answer to, nor have had the opportunity to ask before. Rarely are the offences discussed, as members can feel this is neither the place nor the time; it is a defense against exposure and ‘being laughed at’. As sunshine is considered the best disinfectant, some members prefer to use the artwork as a safe holding space for their thoughts and feelings for fear of exposure and ridicule from their peers. Therefore the group session of an hour is primarily for art making. Any discussion is spontaneous, not forced and not expected. With such changing dynamics in the group it is vital to respect the members need for privacy and refuge.
The weekly group has a tendency to oscillate from chaos to calmness, depending on what feelings are brought into the room and the dynamics in their relationships at the time. The chaos is brought in off the ward but once the group focuses on their art making, a state of calmness is restored. For the facilitator there is much to hold in the space, but understanding is achieved by looking, listening, seeing and watching. The facilitator has the opportunity to reflect back on what is heard and seen, which often encourages discussion, with the clues of their current preoccupations held in the images. One member came to the group having originally declined in the hope of being taken on leave instead. He was told he would be taken to the local community after the group; he spent the group painting an image of leaves.
Another member discovered a talent for oil painting. His work showed more integration of awareness of his humiliated fury, burning resentment and explosive anger held within the group. He painted a sad figure seated on a stool with a small rowing boat around his neck with the words ‘no one’s perfect’ down one side of the canvas and an NHS sign post on the other side of the figure with the words ‘frustration, hope, anger, pain’.
Though this image shows a knowingness rarely seen in the artwork created by the art therapy group, there is still a lack of symbolic functioning in the images. Often meaning is held in the therapists’ mind, whilst the work holds the symbolic equation, waiting to be realized in the mind of its maker. This is a very sensitive stage that has to be worked with carefully in order to contain the emotions there in. The use of images in a group can be gentle yet powerful; their meanings need handling with care to avoid fragmentation or provocation of negative responses from the patient. This is not to say there is an avoidance of negative transference, but to prematurely reawaken the fragile emotions contained in the art work from a warded off (Beail, 1998, 2003, 2004, 2007) or defensive position needs thoughtful handling to reduce the risk of an offence reenactment.
The most important attributes of the group are to offer choice through art materials and art making with no restrictions, but also the chance to be themselves, to find a place to explore their identity and to experiment with reasoning to renegotiate their developmental progress, and to risk attachment to another human being. It’s another chance to learn how to relate to others, which is first encountered through their relationship with their own images and sensory tactile experiences when using the mediums provided by the art psychotherapist. The artwork is kept safely in individual folders in the art therapy room to symbolize a healthy nurturing model mirrored through the art therapy group work. The group is now a recognized and a well held feature of the ward timetable. It often feels like a chance in the busy week to be with others in silence, to become a new (weirdly unconventional) constituted family, to learn from one another, and to see a different way of looking at their lives through art.
“Battle not with monsters, lest ye become a monster, and if you gaze into the abyss, the abyss gazes also into you”. Friedrich Niezsche.
Footnotes
Acknowledgements
I would like to thank Clarabel Jones, copy editor in training (Oxford Brookes University) and Terry Birchmore, for all their considerable support and advice on my article.
Head of Arts Therapies in the Forensic Directorate of an East London Foundation Trust