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Book Forum: Psychotherapy   |    
Art, Psychotherapy, and Psychosis
ALISSA J. HIRSHFELD, M.A., M.F.C.C.
Am J Psychiatry 1998;155:1619a-1620.
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edited by Katherine Killick, and Joy Schaverien. , New York, Routledge 1997, 267 pp., $69.95; $24.99 (paper)

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This book is an engaging collection of 12 essays on the theory, practice, and historical development of the field of art therapy in Britain, specifically regarding the treatment of psychosis. It is intended for a wide readership, internationally as well as from diverse clinical fields. It is organized into two sections. Part 1, Art, Psychotherapy, and Psychosis, consists of six chapters discussing issues of theory and practice, primarily from an analytic perspective, illustrated with case examples and reproductions of artwork. Part 2, Context and History, discusses the historical development of the profession. Most of the patients discussed are diagnosed as having schizophrenia, although some have diagnoses of manic-depressive and paranoid psychosis. However, the case studies will be of interest not only for clinicians who work with psychotic patients but also for those who work with children, adults with learning disabilities, or other nonverbal groups.

The authors included are all registered members of the British Association of Art Therapists. Many have backgrounds as visual artists, and several have Jungian training as well. The two editors, Katherine Killick and Joy Schaverien, are both Jungian analysts. Although sometimes the analysis is a bit heavy-handed and the writing quality uneven, the authors insightfully and inspirationally discuss the healing power of using art to work with psychotic patients.

In the first essay, Schaverien speaks of the artwork as a transactional object that allows the patient a safe way to establish an indirect relationship with the therapist. At first, the artwork is used as a private fetish, invested with magical meaning but not used to relate to the therapist. As trust develops, the artwork is eventually used as a talisman, to communicate and relate to the therapist. Schaverien also explains her theory of scapegoat transference, by which split-off elements of the psyche are externalized in an art piece. It is the therapist’s role to gradually make the intolerable affect tolerable so that the patient can reintegrate it.

In the next chapter, Killick uses case studies to emphasize the importance of creating and maintaining a contained environment when working with psychotic patients with fragile ego boundaries. Many of the writers in this collection reiterate this point, thoroughly describing their work environments and other frame issues. Killick, like many of the writers in this volume, bemoans the difficulty of providing a stable frame in many community settings—the old asylums that provided long-term placements for patients having closed—and makes a plea for such sanctuaries, or, in the words of one of her patients, "places that allow the mind to heal." This point is well-taken in the United States as well. Killick discusses her countertransference feelings with impressive honesty, specifically the potential for feelings of despair and futility.

Fiona Foster, a sculptor, compellingly discusses the parallels between sculpted objects and a body-like form and thus the tendency of psychotic patients to project bad parts of themselves onto the material and then avoid or flatten the clay, perceiving it as a container of projected persecutory forces. By talking about a sculpture outside of the self, the patient slowly feels the safety to begin to re-own split-off feelings and memories.

In a very well-written essay describing one patient with extensive sexual perversions, David Mann insightfully demonstrates how the picture-making process can be used to uphold defensive structures. Mann also makes an interesting distinction between the perverse use of sexuality in psychotic art—wherein the "as if" quality is lost and the patients really believe themselves to be engaged in a sexual act with the painting—and the nonpsychotic use of sexual themes by fine artists.

At this section’s end, Helen Greenwood makes the strong point that in a supportive environment, the ego structures of psychotic patients can be strengthened to enable them to use the higher-level defenses of humor and sublimation.

Part 2 opens with a theoretical piece by David Maclagan questioning the definition of psychotic art and arguing that such a category is culturally defined and that psychotic artists have been influenced in style by the currents of modernism. This raises an interesting point: the thin line between art we define as "psychotic" because it is made by institutionalized individuals and the art that becomes defined as avant garde, some of which is produced by now famous artists who happen to have had a diagnosable mental illness. Maclagan suggests that a transition in social role from psychiatric patient to artist would be healing for many patients.

Chris Wood provides a comprehensive historical overview of the developing field of art therapy, tracing its roots from the 1940s and 1950s, when artists began to work with patients and emphasized the intrinsic nature of art-making as healing, to the antipsychiatry movement of the 1960s and 1970s, when psychotic processes were somewhat romanticized by clinicians influenced by the theories of R.D. Laing and patients’ art productions were viewed more in terms of their creativity than their illness, to the professionalism of the analytic 1980s and 1990s. John Henzell’s autobiographical piece provides a longer discussion of the antipsychiatry movement. It would have been interesting to hear more about the specific therapeutic techniques of clinicians working during this time period, interested as they were in understanding the state of consciousness of their clients rather than medicating it.

The next two pieces, by Claire Skailes and Sue Morter, could have been placed in part 1 because they are more concerned with theory and practice than history. Both rely on case studies to illustrate the sensitivity, care, and respect demanded of clinicians who work with psychotic patients. Skailes’s description of her patients, viewed through a nontheoretical beginner’s mind, as the "walking undead" is particularly poignant for anyone who has worked with such patients. Morter takes an object relations approach in describing the use of her own artwork to mirror one patient’s process. Her piece is particularly illustrative of what an art therapist does in the room with the patient, details of which are left vague in some of the other essays.

Overall, this book convincingly illustrates the benefits of art therapy treatment for psychotic patients and hence provides a strong argument for appropriating more resources for these underserved and often written-off patients.

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