18 Art therapy Art therapy as part of a palliative care programme Camilla Connell Key words: art therapy, case report, healing (non-MESH), paintings, palliative treatment The principle aim in art therapy is to assist patients towards a better understanding of their situation. A case study shows how the role of the therapist is less that of a teacher and more one of questioning companion. It is hoped that this approach will be increasingly recognized as having a valuable part to play in palliative care. Mots-Cl6s: th6raple par I’art, etude de cas, soins alternatifs, traitement palliatif peintures, Le but principal de la th6rapie par I’art est d’aider les patients 6 mieux comprendre leur situation. Une etude de cas montre que le r6le du th6rapeute est moins celui d’un professeur que d’un compagnon qui pose des questions. II faut esp6rer que la valeur de cette approche sera de plus en plus reconnue dans les soins palliatifs. Art therapy is a relatively new discipline. It was first employed in a psychiatric hospital in 1946. Until recently most art therapists have worked in psychiatry, special education and the Social Services. However, for a number of years it has been part of the programme for patients attending the Bristol Cancer Help Centre among other centres. In 1989, the Royal Marsden Hospital was the first National Health Service cancer hospital to establish an art therapy service as part of its newly opened Marie Curie Rehabilitation Centre. Sufficient work has now taken place to Address for correspondence: Camilla Connell, Registered Art Therapist, Royal Marsden Hospital, Fulham Road, London SW3 6JJ, UK. begin to indicate that art and for therapy has a valuable, irreplaceable, part to play in psychological needs of patients some an the the different stages of their illness. There is much of value and interest to be learned here from the work of Susan Bach.l Her pioneering work offers a system of evaluation of spontaneous drawings and paintings by patients who are seriously ill. Whilst acknowledging her great contribution in this area, I have taken a rather different stance. My own feeling is that for patients receiving palliative care the value of forecasting, diagnosing and interpreting possible outcomes from pictures is overshadowed by the need for a patient to be supported in their own search for understanding even if this does not meeting through Downloaded from pmj.sagepub.com at Harvard Libraries on June 28, 2015 19 reach a verbal level. To this end, I try to resist frequent request from patients to tell them what ’I see’ in their picture. Admittedly, repeated a themes appear in the art work I receive, and I can refer to writings on ’archetypal symbolism’ and ’the meaning of images’, but finally the meaning in a picture is the patient’s own and I can only help to explore it with them if they wish. ’It is not the moment of my clever interpretation that is significant.’2 It is very hard to transfer understanding to someone else. Understanding comes from personal experience, not from theory. Art therapy is neither a form of occupational therapy nor merely a pleasant form of diversion. It is not for discovering talent, developing skills, or for appreciation of art. The once fashionable idea in psychology that art therapy is primarily a diagnostic tool should, I believe, be replaced by a broader understanding of the contribution it can make to a person’s well-being. It addresses the psyche on different levels, through visual modes of understanding rather than logical ones, and it is a process which answers the fundamental human need to be creative, especially for someone whose capacities are much reduced through illness. It can be a means of selfaffirmation when other avenues are seemingly denied. The act of image-making can bring inner concerns into consciousness, where they can be viewed more objectively. The opportunity to view concerns more objectively may offer new understandings and be helpful when someone faces questions related to their own life and death. Indeed, Susan Bach states ’It seems that under the pressure of a life and death situation, hitherto untapped sources are activated and I expressed’.1 The therapist has a vital role to play in this process. She has to initiate, offer materials, support, encourage, look, listen and reflect. Art is by no means a desirable activity for everybody but an initial rejection of the offer does not mean that with appropriate support a patient will not change their mind. ’I am no good at drawing’, ’I can’t paint’, ’I was told I was hopeless at school’, ’You couldn’t find anyone less artistic than me’. These types of remark are nearly always offered at first, indeed it is unusual when they are not. So in these initial stages, I try to attune to the patient followed search for their interests and enthusiasms. I offer to show them the book of patient art work that I have collected over the months. In this there is a wide range of experiences depicted and there will always be one or two contributions to which a patient can relate. They see for themselves that most people are not ’artists’ and that there is a choice of materials available paint, carbo-crayons, felt tip pens and so on. I then use terms like ’exploration’, ’experimentation’ and ’the experience and enjoyment of colour’, in order to quieten anxieties about what to paint. I never speak of ’painting your feelings’, ’drawing your cancer’ or even using words like ’play’ which can impute an as yet unacceptable childish element to this unfamiliar venture on the part of the patient. In other words, as therapist I attempt to create a safe space within which the patient can be free to experiment. This exploration contrasts with the conventional ’egocontrolled’ type of art work the same patient might do when alone or at home. For some patients this freedom of expression can be retained, in varying degrees, in the therapist’s absence, but with the knowledge that she will return to offer support and interest in the work that has been done. In contrast to teaching, little direction is given in terms of ideas, skills and technique, unless asked for, although the presence of a therapist is in itself a strong directive influence. At the same time I would not leave a patient poised on the edge of uncertainty for too long, wondering how to begin. It would be quite inappropriate. Art therapy in palliative care is very different from the same discipline in other settings. The therapist does not lead, she can only accompany, for we only go along this road once. Is it possible to assess who would benefit from a creative opportunity of this nature? Is it for everyone, or only a few? It is never possible to judge merely by appearances whether someone would benefit or not. Someone may be very weak and ill and still find the process helpful. For many people it feels like an heroic event to begin to work with art materials. For a few it comes easily. At the initial stage a considerable amount of care and sensitivity is necessary on the part of the therapist. I have found that by offering a genuine relationship, the patient begins to develop trust most immediate concerns of the by a Downloaded from pmj.sagepub.com at Harvard Libraries on June 28, 2015 20 and confidence. This trust enables him or her to view with interest, even excitement, the prospect of using colour, line or form. People have many different motivations when they come to use art. The patient may feel that there is nothing to lose; that painting could provide a window through which to look beyond a very restrictcd existence; that it could be an adventure; or that something good might come out of it. Nonetheless imaginative efforts are often required on the part of the therapist to bring the patient to the point where they will take a voluntary leap into the unknown. For some, even in the end stage of illness, there seems to be an intuition, not fully understood, but strongly felt, that this wordless process of picture-making could serve a purpose in releasing important concerns and even enlightening their situation. From the work which has been done, there is evidence that this indeed is the case. I therefore try not to pass by anyone just because of their debilitated state. However, art work is not for everyone; attitudes about art, fear of encountering the unknown, loss of face, and total absence of interest, all act as barriers and have to be acknowledged. What value does art therapy have for patients? The answer to this question will not be scientifically precise. What can be said is that the value is in the process of creating images and not in the image as an art object. Some of the images patients have created might well live both as records of a process and as art objects in their own right, but that is not their value to art therapy. To a great extent these works speak for themselves, although sometimes spoken or written material associated with it can deepen its meaning for patient and therapist. Art work can answer the needs of an individual on more than one level. It can be simply diversionary without seeming to penetrate further, or it unexpectedly permits the release of powerful feelings, hitherto held in check, which now demand acknowledgement. The process of creating images offers a means of exploring and questioning what is happening in body, mind and spirit. Significantly it can also lead to the immediate experience of faith, hope and an appreciation of what life has brought. As their illness progresses, some people feel a need to re-evaluate their lives and to recognize new situations. For example, art therapy allows a patient to express concerns for their body. Such images often cause the patient some astonishment by what is revealed through this non-verbal medium. Moreover, it is a means of gaining support or communicating with others when words are inadequate or insufficient. Priorities and goals can also be reassessed through picturemaking. Rather than illustrate the several points made here, I will describe how one patient used the opportunity to paint on her last day of full consciousness, the art appearing to assist her to undergo a quite transformative passage. These works were the culmination of a long series of paintings depicting an increasing understanding and psychological growth. ’Atalia’ was a 42-year-old woman. She had struggled with cancer for 10 years, undergoing every form of orthodox and other treatments. She found drawing and painting helpful and had involved herself in art work on each successive admission over the 18 months that I had worked with her. She had been pleased with her increasing skills and the organization she could achieve around her, for example she collected her morphine pots because they were useful for mixing paint. However, she would not admit any interest in why she painted the images she did. Her comment in this respect was that while she was working with me she didn’t know what she was painting and didn’t mind what people thought, but it wasn’t ’art’. ’Art’ was what she did at home, still-life in crayon, the objects being quite recognizable so that people could see that she could draw. The last four paintings illustrated here were made in two and a half hours one afternoon, Atalia sitting in her wheelchair, everything arranged as close as possible. 1 ) The &dquo; painting The paint in this picture was poured on to the paper straight from the pots and then, abandoning the brushes, Atalia used her fingers, getting me to wipe them for her when she changed colour. They were desperate movements, but judgement and care were still exercised as she painted. The sea is turbulent. Thick red paint was applied from the top downwards so, although it could be read as an explosion, I felt it was a plunging into the sea Downloaded from pmj.sagepub.com at Harvard Libraries on June 28, 2015 21 Figure 1 The -.-.-- Figure 2 sea painting _,,, , , ,, z Is this chaos? Downloaded from pmj.sagepub.com at Harvard Libraries on June 28, 2015 22 Figure 3 Pink and Figure 4 The desert with three plants yellow painting Downloaded from pmj.sagepub.com at Harvard Libraries on June 28, 2015 23 Was this one way that someone who is could express their inner needs and emotions? 2) Is this chaos? Again the paint was poured straight from the pots, and then stabbing it with a brush in one hand and a handkerchief in the other held to her eyes, Atalia asked repeatedly: ’Is this chaos?’. She seemed reluctant to finish this painting, adding paint upon paint, finishing with white. 3) Pink and yellow painting The paint was poured on to the paper and a brush was used to depict what Atalia described as the arising of peace and light. 4) The desert with three plants Atalia asked for another sheet of paper and started on her fourth picture, this time she requested crayons, because they were ’quicker’. Before she began she cleaned the crayons carefully as if purity of colour could bring purity of meaning. Everything in this picture is in threes. It is a landscape with three elements, sky, earth and plants. The three plants occupy roughly the left-hand third of the paper. Horizontally it is divided into two parts sky and one part earth. While we never discussed this, it seemed in all this that something within her was not contemplating death at all, and far from indicating a fading away, the work seemed to suggest the opposite. deep. dying Through these four pictures something seems to be distilling; chaos, an immersion, and a rising light and peace, leading to this triple image - the inner structure of unity. In spite of all the disturbances of a hospital ward, this process had seemed untouched and unstoppable. I felt that Atalia had needed increasing support in order that her psyche could fulfil its purposes up to the last possible moment. Our relationship had become increasingly silent. In earlier months Atalia had talked, complained and tried to organize her diminishing world, but finally conversation gave way to painting with only a few remarks being uttered from time to time. I too learned to say less and less. I had visited her three times during that last week, wondering about the possibilities that existed for her in painting. There are, of course, many questions in all this and I do not pretend to have any answers, but I wondered how she would have confronted her passage from life to ’death’ without the art therapy. For those who see the benefits of this type of work for patients, the obvious question is: ’Could we start an activity of this nature in our setting?’ Enthusiasm is important but has to be tempered with caution. For example, is it appropriate for someone who may have art experience or be interested in it as a diversionary activity, to initiate art work with patients? The power of image-making should never be underestimated. On one level it would seem to offer a harmless and pleasant form of entertainment. However, images do not arise solely from the logical part of the mind. In fact, under pressure, they are more likely to spring from much deeper emotional levels, over which we do not have conscious control. Such material which may emerge can have a powerful and sometimes disturbing effect on patient and also therapist. It is important therefore, that she should be able to contain emotional situations that arise safely, and ’establish a therapeutic frame in which the image can be allowed its own authority, without overwhelming the client with its message but also without being stripped of its iconological power’.3 Frequently pictures appear depicting despair, frustration, shock, cynicism, uncertainty, fear, muddle and confusion, loss and sadness. These need to be allowed to stand and to be acknowledged. Yet, having objectified such feelings in a drawing or painting, the maker often experiences relief from the pressure they were exerting. The therapist, however, may find difficulty in remembering that the patient’s feelings are not her feelings and unwittingly become identified with them. Supervision by someone with a psychotherapy training is therefore advisable for a therapist engaging in this work. Reflecting on the way in which the therapy is going allows the therapist to regain their objectivity in relation to the patient and to acknowledge personal issues that may intrude into her professional activity. There is a tendency in all of us to try and make awful situations better. This need to rescue people from their distress and thereby devalue it, needs help to resist. It is in the nature of the work that an art therapist can be endowed by the patient with Downloaded from pmj.sagepub.com at Harvard Libraries on June 28, 2015 24 a certain mystique and power which is at variance with reality. Nonetheless, as a therapist I have to recognize that the process itself is a mysterious one and I cannot claim that I fully understand or am the perpetrator of events that may occur. Such encounters with the image-making process cannot be undertaken casually. Powerful responses are invoked. There are risks therefore for both patient and therapist. Appropriate training is recommended and details can be obtained from the British Association of Art Therapists (BAAT) at lla Richmond Road, Brighton BN2 3RL. Conclusion beginning of this article I stated that a principle aim in art therapy is to assist patients undergoing palliative care towards a better understanding of their situation. I find it important to emphasize that the role of the therapist is not that of a teacher or interpreter, but of a questioning companion. In this capacity the therapist is vital. I have tried briefly to describe the nature of my approach in practical terms. I have also indicated broadly who might benefit from art therapy and cautioned against hastily prejudging who might gain from the experience. I have used one patient’s work as an example of the benefits of such picture-making, although considerable evidence exists to indicate that these benefits can be experienced in a variety of ways and on different levels. Finally, I have tried to share the questions that arise for anyone At the who may wish to undertake this work in a palliative care context. My hope for the future is that art therapy will be increasingly recognized as having a valuable part to play in palliative care. A start has been made, and the indications are, from the work taking place at the Royal Marsden Hospital, that this recognition is growing. Appendix Reflection on - - . ~ ... therapy for patients Surgery, Royal About six months ago I was making a solitary ward round on Ellis ward when I came across a strange lady handing out pots of paints to one of my patients. I assumed she was an occupational therapist who wanted a change from basket-weaving but my curiosity got the better of me and within five minutes of conversation with Camilla Connell I became totally won over to the concept of art therapy for patients with cancer. My interest and enthusiasm can be described at two levels. Firstly there is an uncanny thematic similarity running through the works of many of these patients facing life-threatening disease. It is as if the experience of cancer stimulates some deeply hidden folk memory to evoke the symbolism of life and death, fear and hope. For example the tree as an expression of life and hope is a recurring theme in these works of art, which can be traced back through many cultures to the original ’Etz Chaim’ (the tree of life) of the Old Testament. At an individual level, what I found so moving was the obvious cathartic value of using art to express hidden fears and the progression of the imagery from fear to hope as a sign of recovery and sadly in the reverse direction as a sign of deterioration. There is no doubt that art is a powerful medium for self-expression for frightened patients, who don’t have the words or the will to express themselves verbally. Furthermore, it would appear that many patients have hidden talents. Yet even in the absence of artistic talent, some of the almost childlike and naive pictures are enormously expressive and deeply moving to the observer. I believe that art therapy is a unique vehicle for allowing patients with cancer to express hidden emotions and thus to some extent provide their own psychotherapy. Comments sessions offered by patients during ’It was good to have the pain.’ a brush in my hand and art therapy paint through SS 1990 busy everywhere, the art therapy different, cut off from the rest, like so quite peace.’ ’ the effect of art Michael Baum Professor of Marsden Hospital, London ’It is References ... room seems an island of J K 1990 1 Bach S. Life paints 1990. 2 Winnicott D. its own span. Einsiedeln: Daimon Verlag, Playing and reality. London: Tavistock Publications, 1971: 59. 3 Edwards M. Jungian analytic art therapy. et al. Approaches to art therapy. ‘I found I didn’t worry about what anyone else thought, I was painting just for myself and could enjoy it very much.’ JW 1.5.90 In: Rubin AJ New York: Brunner ’It is no good just sitting there, you must do something.’ CS 11.7.90 Mazel, 1987. Downloaded from pmj.sagepub.com at Harvard Libraries on June 28, 2015 25 ’It is good to release these feelings, it is so surprising what comes up. I can be like this here away from home.’ RC 1990 (Upon completion really had to beat of a painting): ’Phew, that’s better, I this thing.’ LE 1980 ’It is good to be able to be like a child. I think my painting is a bit like the world of Winnie-the-Pooh.’ ’I find painting such a release and so relaxing. It is the creativity that is so helpful.’ JF 1989 ’Painting always gives (Upon completion of me a a lift when I feel low.’ IT 1989 picture): ’It is like a prayer.’ NS 1988 ’When I am painting with you I don’t know what I am doing and I don’t mind what people think.’ NS 1988 , were quite right when you said you didn’t analyse pictures, but what you do do is help to broaden my understanding of my painting for myself by the open- ’You ended comments you make.’ RF 1989 , Downloaded from pmj.sagepub.com at Harvard Libraries on June 28, 2015 .